Basic Information
| Provider Information | |||||||||
| NPI: | 1861941924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOLLEY | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9499 W CHARLESTON BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891177147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029339393 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9499 W CHARLESTON BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891177147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029339393 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2016 | ||||||||
| LastUpdateDate: | 09/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | 150277 | NV | Y |
No ID Information.