Provider Demographics
NPI:1184493405
Name:MCNICHOLAS, LISA MARIE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MCNICHOLAS
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 1:100 S 3RD ST APT 714
Mailing Address - Street 2:
Mailing Address - City:MARTINS FERRY
Mailing Address - State:OH
Mailing Address - Zip Code:43935-1473
Mailing Address - Country:US
Mailing Address - Phone:614-398-8419
Mailing Address - Fax:
Practice Address - Street 1:100 S 3RD ST APT 714
Practice Address - Street 2:
Practice Address - City:MARTINS FERRY
Practice Address - State:OH
Practice Address - Zip Code:43935-1473
Practice Address - Country:US
Practice Address - Phone:614-398-8419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-28
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV125553494Medicaid
WV1821206228Medicaid
WV1356607394Medicaid