=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932914801
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA KIM MAAG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/10/2025
-----------------------------------------------------
Last Update Date | 02/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1726 WESTPORT DR
-----------------------------------------------------
City | KINGS MILLS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45034-9733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-325-9247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1726 WESTPORT DR
-----------------------------------------------------
City | KINGS MILLS
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 45034-9733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 513-325-9247
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number | RU204038
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------