Provider Demographics
NPI:1487216743
Name:WILLIAMS, LISA SUSAN (AGPCNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SUSAN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 WEXFORD DR
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11769-1438
Mailing Address - Country:US
Mailing Address - Phone:516-380-5777
Mailing Address - Fax:
Practice Address - Street 1:76 SOUTHAVEN AVE STE 5
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-3745
Practice Address - Country:US
Practice Address - Phone:631-447-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-07
Last Update Date:2019-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY309193363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health