Provider Demographics
NPI:1194411439
Name:TAYLOR, LISA DIANE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:TAYLOR
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 1:79 N LONGWORTH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:OH
Mailing Address - Zip Code:45640-1414
Mailing Address - Country:US
Mailing Address - Phone:740-978-6241
Mailing Address - Fax:
Practice Address - Street 1:79 N LONGWORTH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-1414
Practice Address - Country:US
Practice Address - Phone:740-978-6241
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-11
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant