Provider Demographics
NPI:1073778676
Name:EVERTS, LISA M (LPN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:EVERTS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 N MEADOW ST
Mailing Address - Street 2:13
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3254
Mailing Address - Country:US
Mailing Address - Phone:607-229-4765
Mailing Address - Fax:
Practice Address - Street 1:320 N MEADOW ST
Practice Address - Street 2:13
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3254
Practice Address - Country:US
Practice Address - Phone:607-229-4765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-23
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY286401-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02887194Medicare PIN