Provider Demographics
NPI:1679739445
Name:SHOVER, LISA LYN (PTA)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:LYN
Last Name:SHOVER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:VT
Mailing Address - Zip Code:05855-5819
Mailing Address - Country:US
Mailing Address - Phone:802-334-6242
Mailing Address - Fax:
Practice Address - Street 1:63 SPRING ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:VT
Practice Address - Zip Code:05855-5819
Practice Address - Country:US
Practice Address - Phone:802-334-6242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-31
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA08228172V00000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility