Provider Demographics
NPI:1891839064
Name:WALLENFELS, LISA (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WALLENFELS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2240 NORTH FOREST RD.
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221
Mailing Address - Country:US
Mailing Address - Phone:716-639-4034
Mailing Address - Fax:716-639-7814
Practice Address - Street 1:1360 N FOREST RD
Practice Address - Street 2:STE 102
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-1200
Practice Address - Country:US
Practice Address - Phone:716-639-4034
Practice Address - Fax:716-639-7814
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF420426363LX0001X
NY420426363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000560362003OtherBCBS
NY9512212OtherIHA