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General NPI Number Information
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NPI Number | 1154489516
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Entity Type | Individual
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Provider Name | LISA GAY WADE OTRL
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Gender | Female
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Dates
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Enumeration Date | 12/05/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 557 GLOVER AVE STE 5
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City | ENTERPRISE
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State | AL
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Zip | 36330-2070
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Country | US
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Telephone | 334-347-0234
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Fax | 334-393-4495
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Provider Business Mailing Address
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Address Line | 557 GLOVER AVE STE 5
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City | ENTERPRISE
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State | AL
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Zip | 36330-2070
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Country | US
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Telephone | 334-347-0234
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Fax | 334-393-4495
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 0106
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License Number State | AL
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