Provider Demographics
NPI:1497076772
Name:GUSSACK, LISA HELEN (RN CNM)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:HELEN
Last Name:GUSSACK
Suffix:
Gender:F
Credentials:RN CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 MAMARONECK AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10528-2400
Mailing Address - Country:US
Mailing Address - Phone:914-421-1500
Mailing Address - Fax:914-421-1501
Practice Address - Street 1:450 MAMARONECK AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10528-2400
Practice Address - Country:US
Practice Address - Phone:914-421-1500
Practice Address - Fax:914-421-1501
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF00109367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYM2M082Medicare PIN