Provider Demographics
NPI:1588670814
Name:LANIER, JILL MARIE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:JILL
Middle Name:MARIE
Last Name:LANIER
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5639 MACCORKLE AVE SW
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1017
Mailing Address - Country:US
Mailing Address - Phone:304-766-0757
Mailing Address - Fax:304-766-0758
Practice Address - Street 1:5639 MACCORKLE AVE SW
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-1017
Practice Address - Country:US
Practice Address - Phone:304-766-0757
Practice Address - Fax:304-766-0758
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV002224225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7302412-000Medicaid
WV7302412-000Medicaid