Provider Demographics
NPI:1437374642
Name:DISTIN, LISA M (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:DISTIN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:733 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-5888
Mailing Address - Country:US
Mailing Address - Phone:315-343-2390
Mailing Address - Fax:315-343-2390
Practice Address - Street 1:4849 OTISCO RD
Practice Address - Street 2:
Practice Address - City:TULLY
Practice Address - State:NY
Practice Address - Zip Code:13159-3086
Practice Address - Country:US
Practice Address - Phone:315-696-8592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY238458-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01789642Medicaid