Provider Demographics
NPI:1962006189
Name:CUNNINGHAM, LISA MARIE
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:CUNNINGHAM
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 1:401 N WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:TAYLORVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62568-1568
Mailing Address - Country:US
Mailing Address - Phone:217-287-7951
Mailing Address - Fax:
Practice Address - Street 1:401 N WEBSTER ST
Practice Address - Street 2:
Practice Address - City:TAYLORVILLE
Practice Address - State:IL
Practice Address - Zip Code:62568-1568
Practice Address - Country:US
Practice Address - Phone:217-287-7951
Practice Address - Fax:217-287-2639
Is Sole Proprietor?:No
Enumeration Date:2020-11-29
Last Update Date:2020-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL051.292185183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist