Provider Demographics
NPI:1255926721
Name:WHITE, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WHITE
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 1:1190 CHILDERS RD
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:WV
Mailing Address - Zip Code:24925-7068
Mailing Address - Country:US
Mailing Address - Phone:304-667-0020
Mailing Address - Fax:
Practice Address - Street 1:1190 CHILDERS RD
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:WV
Practice Address - Zip Code:24925-7068
Practice Address - Country:US
Practice Address - Phone:304-667-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker