Healthcare Provider Details

I. General information

NPI: 1265423784
Provider Name (Legal Business Name): NANCY MARGARET YOUNG LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 03/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR 88 MDOS/SGOWS
WPAFB OH
45433-5336
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR 88 MDOS/SGOWS
WPAFB OH
45433-5336
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-3112
  • Fax:
Mailing address:
  • Phone: 937-257-3112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberI0008455
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: