Provider Demographics
NPI:1790732899
Name:LISAK, MARYANN (RN, MS, PNP)
Entity Type:Individual
Prefix:MS
First Name:MARYANN
Middle Name:
Last Name:LISAK
Suffix:
Gender:F
Credentials:RN, MS, PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 LAKESIDE AVE
Mailing Address - Street 2:SUITE 115
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05401-4939
Mailing Address - Country:US
Mailing Address - Phone:802-860-1928
Mailing Address - Fax:
Practice Address - Street 1:128 LAKESIDE AVE
Practice Address - Street 2:SUITE 115
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-4939
Practice Address - Country:US
Practice Address - Phone:802-860-1928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0019912363LP0808X
VT1010019912363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT6703781Medicaid