Healthcare Provider Details

I. General information

NPI: 1740175314
Provider Name (Legal Business Name): LISA WHITE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 RIDGEWAY DR
BRIDGEPORT WV
26330-1276
US

IV. Provider business mailing address

330 RIDGEWAY DR
BRIDGEPORT WV
26330-1276
US

V. Phone/Fax

Practice location:
  • Phone: 304-627-4116
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: