Provider Demographics
NPI:1669087219
Name:BIRD, LISA RENEE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:BIRD
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 4TH AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25303-1266
Mailing Address - Country:US
Mailing Address - Phone:304-993-4425
Mailing Address - Fax:304-746-5620
Practice Address - Street 1:325 4TH AVE STE 4
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25303-1266
Practice Address - Country:US
Practice Address - Phone:304-746-5600
Practice Address - Fax:304-746-5620
Is Sole Proprietor?:No
Enumeration Date:2020-09-10
Last Update Date:2020-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV76575171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator