Provider Demographics
NPI:1174204234
Name:LOTT, MYIISHA MARIE
Entity type:Individual
Prefix:
First Name:MYIISHA
Middle Name:MARIE
Last Name:LOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 N MCCORD RD
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-3359
Mailing Address - Country:US
Mailing Address - Phone:419-360-0479
Mailing Address - Fax:
Practice Address - Street 1:4540 N MCCORD RD
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-3359
Practice Address - Country:US
Practice Address - Phone:419-360-0479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health