Provider Demographics
NPI:1023207248
Name:GORMAN, LISA MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:GORMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 CAROL CT
Mailing Address - Street 2:
Mailing Address - City:CONKLIN
Mailing Address - State:NY
Mailing Address - Zip Code:13748-1435
Mailing Address - Country:US
Mailing Address - Phone:607-775-9363
Mailing Address - Fax:
Practice Address - Street 1:17 CAROL CT
Practice Address - Street 2:
Practice Address - City:CONKLIN
Practice Address - State:NY
Practice Address - Zip Code:13748-1435
Practice Address - Country:US
Practice Address - Phone:607-775-9363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-24
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY447679-1163WH0200X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02847670Medicaid