Provider Demographics
NPI:1407890130
Name:REARDON, LISA COX (MED)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:COX
Last Name:REARDON
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 761
Mailing Address - Street 2:1627 SKINNER LANE
Mailing Address - City:OAK GROVE
Mailing Address - State:LA
Mailing Address - Zip Code:71263-0761
Mailing Address - Country:US
Mailing Address - Phone:318-428-3249
Mailing Address - Fax:318-428-7547
Practice Address - Street 1:307 NORTH CASTLEMAN STREET
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263-0788
Practice Address - Country:US
Practice Address - Phone:318-428-3249
Practice Address - Fax:318-428-7547
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1183376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1511595Medicaid
195423Medicare ID - Type Unspecified