Provider Demographics
NPI:1285376913
Name:FLOOD BLACK, LISA M
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:FLOOD BLACK
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 1:321 COPENHAVER DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25387-1525
Mailing Address - Country:US
Mailing Address - Phone:304-859-2917
Mailing Address - Fax:
Practice Address - Street 1:321 COPENHAVER DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25387-1525
Practice Address - Country:US
Practice Address - Phone:304-859-2917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant