Provider Demographics
NPI:1326273517
Name:HAGGERTY, LISA (RN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:HAGGERTY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MRS
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:HAGGERTY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:312 ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1039
Mailing Address - Country:US
Mailing Address - Phone:631-423-8755
Mailing Address - Fax:
Practice Address - Street 1:6 EDEN ROC DR
Practice Address - Street 2:
Practice Address - City:LOCUST VALLEY
Practice Address - State:NY
Practice Address - Zip Code:11560-1117
Practice Address - Country:US
Practice Address - Phone:516-671-0378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY364412-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse