Provider Demographics
NPI:1700498300
Name:FOSTER, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:FOSTER
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 1:9562 19TH BAY ST APT A
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23518-6211
Mailing Address - Country:US
Mailing Address - Phone:757-754-1799
Mailing Address - Fax:
Practice Address - Street 1:9562 19TH BAY ST APT A
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23518-6211
Practice Address - Country:US
Practice Address - Phone:757-754-1799
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA929525172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver