Provider Demographics
NPI:1568478253
Name:PROULX, LISA M (RN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:PROULX
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:USA MEDDAC, ATTN CREDENTIALS
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:315-774-5596
Mailing Address - Fax:315-965-7303
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:USA MEDDAC, ATTN CREDENTIALS
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-3546
Practice Address - Fax:315-772-9762
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY696332163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD000Medicare UPIN