Healthcare Provider Details

I. General information

NPI: 1104899541
Provider Name (Legal Business Name): LISA DUVALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 03/25/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 HOSPITAL DR SUITE 1
EVERETT PA
15537-7019
US

IV. Provider business mailing address

227 HOSPITAL DR SUITE 1
EVERETT PA
15537-7019
US

V. Phone/Fax

Practice location:
  • Phone: 814-623-9095
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOS010157L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: