Provider Demographics
NPI:1093307563
Name:JOHNSON-DIMARCO, LISA ANNE (DC)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANNE
Last Name:JOHNSON-DIMARCO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:ANNE
Other - Last Name:DIMARCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:700 WARREN RD APT 18-1E
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1224
Mailing Address - Country:US
Mailing Address - Phone:516-471-0960
Mailing Address - Fax:
Practice Address - Street 1:700 WARREN RD APT 18-1E
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1224
Practice Address - Country:US
Practice Address - Phone:516-471-0960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-06
Last Update Date:2021-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006477111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor