Provider Demographics
NPI:1851072037
Name:LISA M. CAMPANELLA-COPPO, MD FUNCTIONAL MEDICINE & WELLNESS, PC
Entity Type:Organization
Organization Name:LISA M. CAMPANELLA-COPPO, MD FUNCTIONAL MEDICINE & WELLNESS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CAMPANELLA-COPPO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:551-316-7740
Mailing Address - Street 1:637 WYCKOFF AVE STE 383
Mailing Address - Street 2:
Mailing Address - City:WYCKOFF
Mailing Address - State:NJ
Mailing Address - Zip Code:07481-1438
Mailing Address - Country:US
Mailing Address - Phone:551-316-7740
Mailing Address - Fax:
Practice Address - Street 1:504 HAMBURG TPKE STE 202B
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2011
Practice Address - Country:US
Practice Address - Phone:551-316-7740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty