Provider Demographics
NPI:1477158392
Name:MOTA, YILISA
Entity Type:Individual
Prefix:
First Name:YILISA
Middle Name:
Last Name:MOTA
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 1:266 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:MA
Mailing Address - Zip Code:01841-3508
Mailing Address - Country:US
Mailing Address - Phone:978-688-5924
Mailing Address - Fax:978-688-5929
Practice Address - Street 1:266 BROADWAY
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MA
Practice Address - Zip Code:01841-3508
Practice Address - Country:US
Practice Address - Phone:978-688-5924
Practice Address - Fax:978-688-5929
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA23953183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist