Provider Demographics
NPI:1447223128
Name:VERNON, LISA SIMONE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:SIMONE
Last Name:VERNON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:S
Other - Last Name:VERNON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:85 NAUTILUS DR STE A
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2448
Mailing Address - Country:US
Mailing Address - Phone:609-807-1414
Mailing Address - Fax:609-382-0707
Practice Address - Street 1:85 NAUTILUS DR STE A
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2448
Practice Address - Country:US
Practice Address - Phone:609-807-1414
Practice Address - Fax:609-382-0707
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-11
Last Update Date:2020-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA08036500207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI63923Medicare UPIN