Provider Demographics
NPI:1558678185
Name:MENNELLA, LISA MARGARET (TVI)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARGARET
Last Name:MENNELLA
Suffix:
Gender:F
Credentials:TVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:785 W END AVE
Mailing Address - Street 2:5E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5466
Mailing Address - Country:US
Mailing Address - Phone:917-658-1555
Mailing Address - Fax:
Practice Address - Street 1:785 W END AVE
Practice Address - Street 2:5E
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-5466
Practice Address - Country:US
Practice Address - Phone:917-658-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-02
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor