Provider Demographics
NPI:1992475297
Name:THOMPSON, LISA LYNN
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:THOMPSON
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 1:208 CHESHIRE WAY # 1
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25704-2064
Mailing Address - Country:US
Mailing Address - Phone:304-429-0100
Mailing Address - Fax:304-429-0148
Practice Address - Street 1:208 CHESHIRE WAY # 1
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-2064
Practice Address - Country:US
Practice Address - Phone:304-429-0100
Practice Address - Fax:304-429-0148
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVNAMedicaid
WV311208122Medicaid