Provider Demographics
NPI:1699409961
Name:MARSHALL, LISA MARIE (PRSS)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:209 W MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-1413
Mailing Address - Country:US
Mailing Address - Phone:304-663-0621
Mailing Address - Fax:
Practice Address - Street 1:209 W MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-1413
Practice Address - Country:US
Practice Address - Phone:304-574-2100
Practice Address - Fax:304-574-2151
Is Sole Proprietor?:No
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22-937175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist