Provider Demographics
NPI:1639454572
Name:RODRIGUES, LISA M (FNP-BC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:RODRIGUES
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:FARIAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:110 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-2423
Mailing Address - Country:US
Mailing Address - Phone:401-300-5757
Mailing Address - Fax:401-300-5656
Practice Address - Street 1:110 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-2423
Practice Address - Country:US
Practice Address - Phone:401-300-5757
Practice Address - Fax:401-300-5656
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2023-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN214014363LF0000X
RIAPRN02224363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110101456AMedicaid
MA110101456AMedicaid