Provider Demographics
NPI:1205437563
Name:LIESEN, SHARON MARIE
Entity type:Individual
Prefix:
First Name:SHARON
Middle Name:MARIE
Last Name:LIESEN
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 1:145 HILL CARTER PKWY
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:VA
Mailing Address - Zip Code:23005-2327
Mailing Address - Country:US
Mailing Address - Phone:804-798-3112
Mailing Address - Fax:
Practice Address - Street 1:145 HILL CARTER PKWY
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:VA
Practice Address - Zip Code:23005-2327
Practice Address - Country:US
Practice Address - Phone:804-798-3112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-03
Last Update Date:2020-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202010893183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist