Provider Demographics
NPI:1982121448
Name:WOOD, LISA (LPN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WOOD
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 1:1907 S NYSSA PL
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-9094
Mailing Address - Country:US
Mailing Address - Phone:918-688-6803
Mailing Address - Fax:
Practice Address - Street 1:1907 S NYSSA PL
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-9094
Practice Address - Country:US
Practice Address - Phone:918-688-6803
Practice Address - Fax:918-688-6803
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-25
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK58766164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse