Healthcare Provider Details

I. General information

NPI: 1154832608
Provider Name (Legal Business Name): LISA ANN MINOR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1411 MARSHALL ST
MCMECHEN WV
26040-1146
US

IV. Provider business mailing address

1411 MARSHALL ST
MCMECHEN WV
26040-1146
US

V. Phone/Fax

Practice location:
  • Phone: 304-233-4323
  • Fax:
Mailing address:
  • Phone: 304-233-4323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number3810028489
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: