Provider Demographics
NPI:1730889395
Name:GREEN, LISA KAY
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:KAY
Last Name:GREEN
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 1:4206 SPRING HILL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-2239
Mailing Address - Country:US
Mailing Address - Phone:304-419-7922
Mailing Address - Fax:
Practice Address - Street 1:4206 SPRING HILL AVE
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-2239
Practice Address - Country:US
Practice Address - Phone:304-419-7922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant