Provider Demographics
NPI:1851891386
Name:RUNELS, LISHA
Entity Type:Individual
Prefix:
First Name:LISHA
Middle Name:
Last Name:RUNELS
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 1:607 S EMMA ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75426-3510
Mailing Address - Country:US
Mailing Address - Phone:903-933-1089
Mailing Address - Fax:
Practice Address - Street 1:607 S EMMA ST
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TX
Practice Address - Zip Code:75426-3510
Practice Address - Country:US
Practice Address - Phone:903-933-1089
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216880164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164X00000XNursing Service ProvidersLicensed Vocational NurseGroup - Single Specialty