Provider Demographics
NPI:1962172734
Name:ELMORE, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ELMORE
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 1:19 BLUE STONE DR
Mailing Address - Street 2:
Mailing Address - City:KENNA
Mailing Address - State:WV
Mailing Address - Zip Code:25248-7129
Mailing Address - Country:US
Mailing Address - Phone:304-932-9324
Mailing Address - Fax:
Practice Address - Street 1:19 BLUE STONE DR
Practice Address - Street 2:
Practice Address - City:KENNA
Practice Address - State:WV
Practice Address - Zip Code:25248-7129
Practice Address - Country:US
Practice Address - Phone:304-932-9324
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant