Individual
LISA A. PROVANCE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
PO BOX 897, MORGANTOWN, WV 26507-0897
(304) 285-7100
(304) 842-2333
Mailing address
PO BOX 897, MORGANTOWN, WV 26507-0897
(304) 285-7100
(304) 842-2333
Taxonomy
Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
0024165328
VA
363LF0000X
Family Nurse Practitioner
Primary
115829
WV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0001104234
RN LICENSE NUMBER
VA
01
—
0024165328
NURSE PRACTITIONER NUMBER
VA
05
—
010114641
—
VA
01
—
014944V57
MEDICARE FOR VHPG
VA
01
—
115829
APRN
WV
Enumeration date
11/08/2005
Last updated
06/08/2024
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