Provider Demographics
NPI:1427274117
Name:HOLDER, LISA JO
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JO
Last Name:HOLDER
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 1:312 W DARBY DR
Mailing Address - Street 2:
Mailing Address - City:OTTERBEIN
Mailing Address - State:IN
Mailing Address - Zip Code:47970-8563
Mailing Address - Country:US
Mailing Address - Phone:765-583-2505
Mailing Address - Fax:
Practice Address - Street 1:312 W DARBY DR
Practice Address - Street 2:
Practice Address - City:OTTERBEIN
Practice Address - State:IN
Practice Address - Zip Code:47970-8563
Practice Address - Country:US
Practice Address - Phone:765-583-2505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0510023691172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver