Provider Demographics
NPI:1215230735
Name:GREGG, LISA A (LPN)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:A
Last Name:GREGG
Suffix:
Gender:F
Credentials:LPN
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 78
Mailing Address - Street 2:
Mailing Address - City:OLD FORT
Mailing Address - State:OH
Mailing Address - Zip Code:44861-0078
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8072 FORT ST.
Practice Address - Street 2:
Practice Address - City:OLD FORT
Practice Address - State:OH
Practice Address - Zip Code:44861-0078
Practice Address - Country:US
Practice Address - Phone:419-934-0959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-07
Last Update Date:2010-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN-135374-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse