Provider Demographics
NPI:1841562683
Name:MAYFIELD, LISA BETH
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:BETH
Last Name:MAYFIELD
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 1:7653 FABLED FILIGREE ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89149-0435
Mailing Address - Country:US
Mailing Address - Phone:702-789-8522
Mailing Address - Fax:
Practice Address - Street 1:7653 FABLED FILIGREE ST
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-0435
Practice Address - Country:US
Practice Address - Phone:702-789-8522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-08
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV20121065010332U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332U00000XSuppliersHome Delivered Meals
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVNV20121065010OtherPROFESSIONAL LICENSE NUMBER