Provider Demographics
NPI:1700392362
Name:PERRY, LISA N
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:N
Last Name:PERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S COLUMBUS AVE APT D1
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10553-1552
Mailing Address - Country:US
Mailing Address - Phone:347-600-3417
Mailing Address - Fax:
Practice Address - Street 1:203 S COLUMBUS AVE APT D1
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10553-1552
Practice Address - Country:US
Practice Address - Phone:347-600-3417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-19
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY330830164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse