Individual
LISA ANN PROVOST
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
CRNA
Contact information
Practice address
401 MATTHEW ST, MARIETTA, OH 45750-1635
(740) 376-1994
(740) 376-1940
Mailing address
PO BOX 449, MARIETTA, OH 45750-0449
(740) 374-4500
(740) 374-5887
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
3485A
KY
367500000X
Certified Registered Nurse Anesthetist
Primary
COA.04992-NA
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000339679
ANTHEM BLUE CROSS BLUE SHIELD
KY
05
—
0069080000
—
WV
05
—
0282617
—
OH
05
—
74472408
—
KY
Enumeration date
03/02/2006
Last updated
12/13/2017
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