Provider Demographics
NPI:1053919357
Name:GILL, LISA MICHELLE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:GILL
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:PO BOX 4
Mailing Address - Street 2:
Mailing Address - City:WALLBACK
Mailing Address - State:WV
Mailing Address - Zip Code:25285-0004
Mailing Address - Country:US
Mailing Address - Phone:304-587-4385
Mailing Address - Fax:
Practice Address - Street 1:145 MAPLE LANE
Practice Address - Street 2:
Practice Address - City:WALLBACK
Practice Address - State:WV
Practice Address - Zip Code:25285
Practice Address - Country:US
Practice Address - Phone:304-587-4385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2022-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant