Provider Demographics
NPI:1518748185
Name:FRADELLA, LYSSA M (CNP)
Entity Type:Individual
Prefix:
First Name:LYSSA
Middle Name:M
Last Name:FRADELLA
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4730 BECKNER ROAD
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87507
Mailing Address - Country:US
Mailing Address - Phone:505-989-4500
Mailing Address - Fax:505-443-8313
Practice Address - Street 1:4730 BECKNER RD
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87507
Practice Address - Country:US
Practice Address - Phone:505-989-4500
Practice Address - Fax:505-443-8313
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-10
Last Update Date:2023-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM76211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily