Provider Demographics
NPI:1184657751
Name:DEDOMENICO, LISA M (CRNP, MSN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DEDOMENICO
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Gender:F
Credentials:CRNP, MSN
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Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:190 WELLES ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-4968
Practice Address - Country:US
Practice Address - Phone:570-714-1099
Practice Address - Fax:570-714-1116
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2020-07-30
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Provider Licenses
StateLicense IDTaxonomies
PATP001029G363LX0001X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology