Provider Demographics
NPI:1396373122
Name:COLEMAN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:COLEMAN
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 1:370 W 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:370 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1238
Practice Address - Country:US
Practice Address - Phone:614-292-7137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-28
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1000XAmbulatory Health Care FacilitiesClinic/CenterStudent Health