Healthcare Provider Details

I. General information

NPI: 1962697680
Provider Name (Legal Business Name): CAROL L LIES LMP-CR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2007
Last Update Date: 09/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 NE 78TH ST
VANCOUVER WA
98665-9666
US

IV. Provider business mailing address

3870 ADDY ST
WASHOUGAL WA
98671-2705
US

V. Phone/Fax

Practice location:
  • Phone: 360-903-5758
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number16389
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: