=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831777291
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA MICKLEY MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2021
-----------------------------------------------------
Last Update Date | 07/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 725 VOLVO PKWY STE 102
-----------------------------------------------------
City | CHESAPEAKE
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23320-1621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-842-4110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 7068
-----------------------------------------------------
City | PORTSMOUTH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23707-0068
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-686-3500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 0101282278
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------