Healthcare Provider Details

I. General information

NPI: 1649361049
Provider Name (Legal Business Name): LISA AMAN LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BARBREY DR
EASLEY SC
29640-7689
US

IV. Provider business mailing address

120 BARBREY DR
EASLEY SC
29640
US

V. Phone/Fax

Practice location:
  • Phone: 864-836-8982
  • Fax:
Mailing address:
  • Phone: 864-836-8982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberLM0001
License Number StateSC

VII. Legacy identifiers

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

# 1
IdentifierLM0002
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: