Provider Demographics
NPI:1376134452
Name:CORDELL, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CORDELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 E WATER ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-2757
Mailing Address - Country:US
Mailing Address - Phone:740-656-5576
Mailing Address - Fax:
Practice Address - Street 1:431 MAPLE DRIVE
Practice Address - Street 2:15
Practice Address - City:FRANKFORT
Practice Address - State:OH
Practice Address - Zip Code:45628-4562
Practice Address - Country:US
Practice Address - Phone:740-656-5576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH04240943747P1801X
OH3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0424094Medicaid