Provider Demographics
NPI:1497316822
Name:GEARLDS, LISA DAWN
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:DAWN
Last Name:GEARLDS
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:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:EDMONTON
Mailing Address - State:KY
Mailing Address - Zip Code:42129-0004
Mailing Address - Country:US
Mailing Address - Phone:270-590-2000
Mailing Address - Fax:
Practice Address - Street 1:414 W STOCKTON ST
Practice Address - Street 2:
Practice Address - City:EDMONTON
Practice Address - State:KY
Practice Address - Zip Code:42129-9435
Practice Address - Country:US
Practice Address - Phone:270-590-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Single Specialty