Provider Demographics
NPI:1700435518
Name:VAZ, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VAZ
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 1:2335 MONUMENT RD
Mailing Address - Street 2:
Mailing Address - City:MYERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21773-8511
Mailing Address - Country:US
Mailing Address - Phone:301-293-3189
Mailing Address - Fax:
Practice Address - Street 1:1595 BOWIS DR
Practice Address - Street 2:
Practice Address - City:POINT OF ROCKS
Practice Address - State:MD
Practice Address - Zip Code:21777-2098
Practice Address - Country:US
Practice Address - Phone:304-860-9022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer