Healthcare Provider Details

I. General information

NPI: 1255978060
Provider Name (Legal Business Name): TERESA LYNN LISUM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2019
Last Update Date: 11/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5261 BROADWAY AVE
NEWTON FALLS OH
44444-1893
US

IV. Provider business mailing address

5261 BROADWAY AVE
NEWTON FALLS OH
44444-1893
US

V. Phone/Fax

Practice location:
  • Phone: 330-307-7296
  • Fax:
Mailing address:
  • Phone: 330-307-7296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: