Provider Demographics
NPI:1508086398
Name:DUFFY, LISA JOAN (CRNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JOAN
Last Name:DUFFY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 SOUTH WYOMING AVENUE SUITE 2
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18704
Mailing Address - Country:US
Mailing Address - Phone:570-824-2800
Mailing Address - Fax:570-718-1476
Practice Address - Street 1:75 SOUTH WYOMING AVENUE SUITE 2
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:PA
Practice Address - Zip Code:18704
Practice Address - Country:US
Practice Address - Phone:570-824-2800
Practice Address - Fax:570-718-1476
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP006462B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102377793Medicaid
PA102377793Medicaid