Provider Demographics
NPI:1760035463
Name:TUMBLIN, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TUMBLIN
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 1:74 CEDAR LN # 184
Mailing Address - Street 2:
Mailing Address - City:ROSELLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07203-3006
Mailing Address - Country:US
Mailing Address - Phone:201-259-6630
Mailing Address - Fax:
Practice Address - Street 1:74 CEDAR LN # 184
Practice Address - Street 2:
Practice Address - City:ROSELLE
Practice Address - State:NJ
Practice Address - Zip Code:07203-3006
Practice Address - Country:US
Practice Address - Phone:201-259-6630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ32WG00789000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist