Provider Demographics
NPI:1639192768
Name:ANDRAKAKOS, LISSA B (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:LISSA
Middle Name:B
Last Name:ANDRAKAKOS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15757 CRABBS BRANCH WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20855-2634
Mailing Address - Country:US
Mailing Address - Phone:301-670-0358
Mailing Address - Fax:301-670-4636
Practice Address - Street 1:15757 CRABBS BRANCH WAY
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20855-2634
Practice Address - Country:US
Practice Address - Phone:301-670-0358
Practice Address - Fax:301-670-4636
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR079598363LC0200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD611643Medicare ID - Type Unspecified
S87390Medicare UPIN