Provider Demographics
NPI:1629195649
Name:PICK, LISA ELLEN (LPN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ELLEN
Last Name:PICK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 WHITE ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NY
Mailing Address - Zip Code:13323-3733
Mailing Address - Country:US
Mailing Address - Phone:315-853-8748
Mailing Address - Fax:
Practice Address - Street 1:64 WHITE ST APT 1
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NY
Practice Address - Zip Code:13323-3733
Practice Address - Country:US
Practice Address - Phone:315-853-8748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197832-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01164603Medicaid