Provider Demographics
NPI:1801136122
Name:WALL, LISA MARIE (LPN)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:WALL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:659 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-3101
Mailing Address - Country:US
Mailing Address - Phone:307-751-9624
Mailing Address - Fax:
Practice Address - Street 1:659 E 5TH ST
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-3101
Practice Address - Country:US
Practice Address - Phone:307-751-9624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-23
Last Update Date:2013-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLPN30652164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse