Provider Demographics
NPI:1477627198
Name:TESORIERO, LISA MARIE
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:TESORIERO
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 1:261 MAIDEN LANE RD
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-5867
Mailing Address - Country:US
Mailing Address - Phone:315-342-4326
Mailing Address - Fax:
Practice Address - Street 1:261 MAIDEN LANE RD
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-5867
Practice Address - Country:US
Practice Address - Phone:315-342-4326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY242424-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01869272Medicaid