Healthcare Provider Details

I. General information

NPI: 1427405588
Provider Name (Legal Business Name): MRS. LISA NICOLE GILLISPIE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2016
Last Update Date: 05/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1943 PAINT CREEK RD
STANTON KY
40380-9418
US

IV. Provider business mailing address

1943 PAINT CREEK RD
STANTON KY
40380-9418
US

V. Phone/Fax

Practice location:
  • Phone: 606-663-0688
  • Fax: 606-663-0688
Mailing address:
  • Phone: 606-663-0688
  • Fax: 606-663-0688

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number000078761
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: