Provider Demographics
NPI:1053689570
Name:PEARL, LISA
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:PEARL
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 1:1 CATHERINE ST
Mailing Address - Street 2:
Mailing Address - City:FORT ANN
Mailing Address - State:NY
Mailing Address - Zip Code:12827-5039
Mailing Address - Country:US
Mailing Address - Phone:518-639-5594
Mailing Address - Fax:518-639-8911
Practice Address - Street 1:1 CATHERINE ST
Practice Address - Street 2:
Practice Address - City:FORT ANN
Practice Address - State:NY
Practice Address - Zip Code:12827-5039
Practice Address - Country:US
Practice Address - Phone:518-639-5594
Practice Address - Fax:518-639-8911
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2011-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY563221-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool