Provider Demographics
NPI:1942565684
Name:MOUNDEMIS, LISETTE
Entity Type:Individual
Prefix:
First Name:LISETTE
Middle Name:
Last Name:MOUNDEMIS
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 1:3402 DEAN DRIVE
Mailing Address - Street 2:APT. # 204
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782
Mailing Address - Country:US
Mailing Address - Phone:202-520-3689
Mailing Address - Fax:
Practice Address - Street 1:3402 DEAN DRIVE
Practice Address - Street 2:APT. # 204
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782
Practice Address - Country:US
Practice Address - Phone:202-520-3689
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide