Basic Information
| Provider Information | |||||||||
| NPI: | 1780132571 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCLOUD | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | SUE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 184 EAST 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042352930 | ||||||||
| FaxNumber: | 3042354202 | ||||||||
| Practice Location | |||||||||
| Address1: | 184 E 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSON | ||||||||
| State: | WV | ||||||||
| PostalCode: | 256613602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042352930 | ||||||||
| FaxNumber: | 3042354202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2016 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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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 | 364SF0001X | 61706 | WV | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Family Health |
ID Information
| ID | Type | State | Issuer | Description | 2016009648 | 01 | WV | ANCC CERTIFICATION # | OTHER |