Provider Demographics
NPI:1780132571
Name:MCCLOUD, LISA SUE (FNP-BC)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:SUE
Last Name:MCCLOUD
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:184 EAST 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSON
Mailing Address - State:WV
Mailing Address - Zip Code:25661
Mailing Address - Country:US
Mailing Address - Phone:304-235-2930
Mailing Address - Fax:304-235-4202
Practice Address - Street 1:184 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:WILLIAMSON
Practice Address - State:WV
Practice Address - Zip Code:25661-3602
Practice Address - Country:US
Practice Address - Phone:304-235-2930
Practice Address - Fax:304-235-4202
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV61706364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2016009648OtherANCC CERTIFICATION #