Provider Demographics
NPI:1316774219
Name:SAMODELL, LISA
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:SAMODELL
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 1:1023 MECHANIC AVE
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-1405
Mailing Address - Country:US
Mailing Address - Phone:330-861-2170
Mailing Address - Fax:
Practice Address - Street 1:1023 MECHANIC AVE
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-1405
Practice Address - Country:US
Practice Address - Phone:330-861-2170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No376J00000XNursing Service Related ProvidersHomemaker