MEDICARE: LISA A. PROVANCE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	0024165328	VA
2	363LF0000X	Family Nurse Practitioner	115829	WV

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	014944V57	OTHER	VA	MEDICARE FOR VHPG

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0024165328	OTHER	VA	NURSE PRACTITIONER NUMBER
2	115829	OTHER	WV	APRN
4	0001104234	OTHER	VA	RN LICENSE NUMBER
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588645378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA A. PROVANCE NP

Provider Business Mailing Address
First Line	:	PO BOX 897
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26507-0897
Country	:	US
Telephone Number	:	304-285-7100
Fax Number	:	304-842-2333

Provider Business Practice Location Address
First Line	:	PO BOX 897
Second Line	:
City	:	MORGANTOWN
State	:	WV
Zip	:	26507-0897
Country	:	US
Telephone Number	:	304-285-7100
Fax Number	:	304-842-2333

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/08/2005
Last Update Date	:	06/08/2024

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Directions to “ LISA A. PROVANCE NP” Practice Location

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