Provider Demographics
NPI:1043590383
Name:PROBER, LISA MARIE
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:PROBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 DUNCAN ST
Mailing Address - Street 2:
Mailing Address - City:CLYDE
Mailing Address - State:NY
Mailing Address - Zip Code:14433-1029
Mailing Address - Country:US
Mailing Address - Phone:315-730-8625
Mailing Address - Fax:
Practice Address - Street 1:46 DUNCAN ST
Practice Address - Street 2:
Practice Address - City:CLYDE
Practice Address - State:NY
Practice Address - Zip Code:14433-1029
Practice Address - Country:US
Practice Address - Phone:315-730-8625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-18
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY291032-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse