Provider Demographics
NPI:1053970269
Name:PADMORE, LISANNE JENEL
Entity type:Individual
Prefix:
First Name:LISANNE
Middle Name:JENEL
Last Name:PADMORE
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 1:526 HIGH ST APT 203
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-3832
Mailing Address - Country:US
Mailing Address - Phone:732-713-0519
Mailing Address - Fax:
Practice Address - Street 1:1411 PRINCESS ANNE ST
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3832
Practice Address - Country:US
Practice Address - Phone:540-922-1110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
106S00000XOtherNONE