Provider Demographics
NPI:1700361813
Name:ELMORE, LISA RENEE'
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE'
Last Name:ELMORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 RAINBOW DR
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24078-2637
Mailing Address - Country:US
Mailing Address - Phone:434-822-3119
Mailing Address - Fax:
Practice Address - Street 1:30510 JEB STUART HWY
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:VA
Practice Address - Zip Code:24165-3585
Practice Address - Country:US
Practice Address - Phone:434-822-3119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver