Provider Demographics
NPI:1942536305
Name:DIQUOLLO, LISA
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:DIQUOLLO
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 1:127 W FAIRBANKS AVE
Mailing Address - Street 2:NO. 240
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-4326
Mailing Address - Country:US
Mailing Address - Phone:407-312-7876
Mailing Address - Fax:
Practice Address - Street 1:1910 ALDEN RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1403
Practice Address - Country:US
Practice Address - Phone:407-898-7911
Practice Address - Fax:407-898-7912
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA42355225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist