Provider Demographics
NPI:1518603141
Name:CHUDOBA, LISA ANNE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:CHUDOBA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:87 MEAD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-4444
Mailing Address - Country:US
Mailing Address - Phone:716-204-5925
Mailing Address - Fax:716-815-6926
Practice Address - Street 1:87 MEAD ST
Practice Address - Street 2:
Practice Address - City:NORTH TONAWANDA
Practice Address - State:NY
Practice Address - Zip Code:14120-4444
Practice Address - Country:US
Practice Address - Phone:716-204-5925
Practice Address - Fax:716-815-6926
Is Sole Proprietor?:No
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator