Provider Demographics
NPI:1609113133
Name:DIALS, LISA MARIE (CCNS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:DIALS
Suffix:
Gender:F
Credentials:CCNS
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 636643
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6643
Mailing Address - Country:US
Mailing Address - Phone:440-988-1009
Mailing Address - Fax:440-988-1227
Practice Address - Street 1:578 N LEAVITT RD
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:OH
Practice Address - Zip Code:44001-1131
Practice Address - Country:US
Practice Address - Phone:440-989-3801
Practice Address - Fax:440-988-1227
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.13374-NS364SC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0082382Medicaid
OH3025372Medicaid
OH0082382Medicaid
OH9389631Medicare PIN
OH3025372Medicaid