Provider Demographics
NPI:1639627375
Name:MASCIOLI, LISA MARIE (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:MASCIOLI
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:385 WIRTZ DR
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-3067
Mailing Address - Country:US
Mailing Address - Phone:815-306-2777
Mailing Address - Fax:815-306-2778
Practice Address - Street 1:385 WIRTZ DR
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-3067
Practice Address - Country:US
Practice Address - Phone:815-306-2777
Practice Address - Fax:815-306-2778
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.019809363LP0808X
IL277002175363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2846675Medicaid