Provider Demographics
NPI:1518276781
Name:DAVIS, LISA DIANE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DIANE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 W GRANT ST
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-2836
Mailing Address - Country:US
Mailing Address - Phone:937-451-2142
Mailing Address - Fax:
Practice Address - Street 1:1616 W GRANT ST
Practice Address - Street 2:
Practice Address - City:PIQUA
Practice Address - State:OH
Practice Address - Zip Code:45356-2836
Practice Address - Country:US
Practice Address - Phone:937-451-2142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN137870164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse