Provider Demographics
NPI:1992925648
Name:QUEEN, LISA (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:QUEEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1563 SAND PLANT RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-6120
Mailing Address - Country:US
Mailing Address - Phone:304-756-1500
Mailing Address - Fax:304-756-1548
Practice Address - Street 1:7400 LYNN AVE
Practice Address - Street 2:
Practice Address - City:HAMLIN
Practice Address - State:WV
Practice Address - Zip Code:25523-1138
Practice Address - Country:US
Practice Address - Phone:304-824-5806
Practice Address - Fax:304-824-5885
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2013-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV49029363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1071586OtherWV DWC
WV3810021657Medicaid
WV001984820OtherBLUE CROSS BLUE SHIELD
WVWV2376GMedicare Oscar/Certification
WVWV2376AMedicare Oscar/Certification
WVWV2376B663Medicare Oscar/Certification
WVWV2376CMedicare Oscar/Certification
WVWV2376DMedicare Oscar/Certification
WV23513Medicare PIN
WV001984820OtherBLUE CROSS BLUE SHIELD
WVWV2376HMedicare Oscar/Certification
MIP00607187Medicare PIN
WV23511Medicare PIN
WVWV2376FMedicare Oscar/Certification
WV23512Medicare PIN
WV3810021657Medicaid
WVWV2376B662Medicare Oscar/Certification