Provider Demographics
NPI:1235596016
Name:KLOSTERBOER, LISA (CPNP AC/PC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KLOSTERBOER
Suffix:
Gender:F
Credentials:CPNP AC/PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 WOODLEIGH RD
Mailing Address - Street 2:
Mailing Address - City:DEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02026-3116
Mailing Address - Country:US
Mailing Address - Phone:781-461-8830
Mailing Address - Fax:
Practice Address - Street 1:14 WOODLEIGH RD
Practice Address - Street 2:
Practice Address - City:DEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02026-3116
Practice Address - Country:US
Practice Address - Phone:781-461-8830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA175700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner