Provider Demographics
NPI:1659680783
Name:PROVENCE, LISA D'NAE (DPT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D'NAE
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:DPT
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 320
Mailing Address - Street 2:
Mailing Address - City:AMHERST
Mailing Address - State:TX
Mailing Address - Zip Code:79312-0320
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 MAIN STREET
Practice Address - Street 2:
Practice Address - City:AMHERST
Practice Address - State:TX
Practice Address - Zip Code:79312
Practice Address - Country:US
Practice Address - Phone:806-246-3483
Practice Address - Fax:806-246-3483
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2010-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1184670225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist