Provider Demographics
NPI:1790182558
Name:STANSBURY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:STANSBURY
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 1:1350 WHITE BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:CHITTENANGO
Mailing Address - State:NY
Mailing Address - Zip Code:13037-9453
Mailing Address - Country:US
Mailing Address - Phone:315-720-2556
Mailing Address - Fax:
Practice Address - Street 1:1603 COURT STREET
Practice Address - Street 2:ENABLE
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13208
Practice Address - Country:US
Practice Address - Phone:315-455-7591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2014-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1168694174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist