Provider Demographics
NPI:1740803923
Name:WIMBLEY, LISA DARNETTE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DARNETTE
Last Name:WIMBLEY
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 1:3430 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2202
Mailing Address - Country:US
Mailing Address - Phone:313-405-9460
Mailing Address - Fax:
Practice Address - Street 1:3430 3RD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2202
Practice Address - Country:US
Practice Address - Phone:313-405-9460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-22
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist