Provider Demographics
NPI:1114143419
Name:PROCTOR, LISA (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:PROCTOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 VANWOERT RD
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:NY
Mailing Address - Zip Code:14883-9721
Mailing Address - Country:US
Mailing Address - Phone:607-589-6826
Mailing Address - Fax:
Practice Address - Street 1:310 TAUGHANNOCK BLVD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3251
Practice Address - Country:US
Practice Address - Phone:607-252-3590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430338363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care