Provider Demographics
NPI:1124715396
Name:MCCLURE, LISA SPEEDE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:SPEEDE
Last Name:MCCLURE
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 1:257 TRIPLE C DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23927-2560
Mailing Address - Country:US
Mailing Address - Phone:434-774-5743
Mailing Address - Fax:
Practice Address - Street 1:143 INDUSTRIAL PKWY
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:VA
Practice Address - Zip Code:23927-3140
Practice Address - Country:US
Practice Address - Phone:434-572-6916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-19
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186346363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health