Provider Demographics
NPI:1922798701
Name:FONTANINI, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:FONTANINI
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 1:1226 MANASSAS LN
Mailing Address - Street 2:
Mailing Address - City:LONG GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60047-5085
Mailing Address - Country:US
Mailing Address - Phone:773-457-3963
Mailing Address - Fax:
Practice Address - Street 1:1226 MANASSAS LN
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047-5085
Practice Address - Country:US
Practice Address - Phone:773-457-3963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.026950363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner