Provider Demographics
NPI:1861685091
Name:KMIECIAK, LISA MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:KMIECIAK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:87 W PINE ST.
Mailing Address - Street 2:PO BOX 300
Mailing Address - City:SHEPPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18248-0300
Mailing Address - Country:US
Mailing Address - Phone:570-384-1070
Mailing Address - Fax:
Practice Address - Street 1:87 W PINE ST.
Practice Address - Street 2:
Practice Address - City:SHEPPTON
Practice Address - State:PA
Practice Address - Zip Code:18248-0300
Practice Address - Country:US
Practice Address - Phone:570-384-1070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN256867L164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse