Provider Demographics
NPI:1992994578
Name:MCCLURE, LISA DIANNE (LPN 880563)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DIANNE
Last Name:MCCLURE
Suffix:
Gender:F
Credentials:LPN 880563
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 RAINBOW DR UNIT 35
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-6979
Mailing Address - Country:US
Mailing Address - Phone:318-487-5191
Mailing Address - Fax:318-487-5453
Practice Address - Street 1:401 RAINBOW DR UNIT 35
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-6979
Practice Address - Country:US
Practice Address - Phone:318-487-5191
Practice Address - Fax:318-487-5453
Is Sole Proprietor?:No
Enumeration Date:2007-10-18
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALPN 880563164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5DL60Medicare PIN