Provider Demographics
NPI:1346388808
Name:LYSIAK, JULIE ELLEN (RN MS CS)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:ELLEN
Last Name:LYSIAK
Suffix:
Gender:F
Credentials:RN MS CS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24 ASNEBUMSKIT RD
Mailing Address - Street 2:
Mailing Address - City:PAXTON
Mailing Address - State:MA
Mailing Address - Zip Code:01612-1351
Mailing Address - Country:US
Mailing Address - Phone:508-752-5621
Mailing Address - Fax:
Practice Address - Street 1:148 WORCESTER ST
Practice Address - Street 2:
Practice Address - City:WEST BOYLSTON
Practice Address - State:MA
Practice Address - Zip Code:01583-1751
Practice Address - Country:US
Practice Address - Phone:508-835-1735
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA210641163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent