Provider Demographics
NPI:1174821219
Name:ANDRAMUNO, LISSETTE
Entity Type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:ANDRAMUNO
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 1:10963 54TH AVE # 3
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:NY
Mailing Address - Zip Code:11368-3337
Mailing Address - Country:US
Mailing Address - Phone:718-414-9959
Mailing Address - Fax:
Practice Address - Street 1:10963 54TH AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:NY
Practice Address - Zip Code:11368-1576
Practice Address - Country:US
Practice Address - Phone:718-414-9959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-13
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016565-1171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor