Provider Demographics
NPI:1033461496
Name:GERVASI, LISA L (RN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:L
Last Name:GERVASI
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 1:121 BACK WINTERPORT RD
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04444
Mailing Address - Country:US
Mailing Address - Phone:207-852-7192
Mailing Address - Fax:
Practice Address - Street 1:1604 BENTON AVE
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:ME
Practice Address - Zip Code:04901-3327
Practice Address - Country:US
Practice Address - Phone:207-453-4708
Practice Address - Fax:207-453-6250
Is Sole Proprietor?:No
Enumeration Date:2012-10-10
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER057352163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse