Provider Demographics
NPI:1174298533
Name:RODRIGUEZ, LISSETH
Entity Type:Individual
Prefix:
First Name:LISSETH
Middle Name:
Last Name:RODRIGUEZ
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 1:790 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-4516
Mailing Address - Country:US
Mailing Address - Phone:631-427-3700
Mailing Address - Fax:
Practice Address - Street 1:316 ACCOBONAC RD
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11937-1931
Practice Address - Country:US
Practice Address - Phone:631-324-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program