Provider Demographics
NPI:1255824645
Name:TANAKA, LISA ANN
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:TANAKA
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 1:11 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MASTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11951-1105
Mailing Address - Country:US
Mailing Address - Phone:631-903-7609
Mailing Address - Fax:
Practice Address - Street 1:11 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MASTIC BEACH
Practice Address - State:NY
Practice Address - Zip Code:11951-1105
Practice Address - Country:US
Practice Address - Phone:631-903-7609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-11
Last Update Date:2018-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY687936163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse