Provider Demographics
NPI:1003700493
Name:GOSS, LISA RENEE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:GOSS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 MILL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOPE
Mailing Address - State:WV
Mailing Address - Zip Code:25880-1549
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6015 MOUNT VIEW RD
Practice Address - Street 2:
Practice Address - City:JUMPING BRANCH
Practice Address - State:WV
Practice Address - Zip Code:25969-9426
Practice Address - Country:US
Practice Address - Phone:304-573-1554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-09
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide