Provider Demographics
NPI:1952647836
Name:LISOWSKI, ROSE M (LMP)
Entity Type:Individual
Prefix:MRS
First Name:ROSE
Middle Name:M
Last Name:LISOWSKI
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14856 W AMELIA AVE
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85395-8205
Mailing Address - Country:US
Mailing Address - Phone:253-389-5302
Mailing Address - Fax:
Practice Address - Street 1:14856 W AMELIA AVE
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-8205
Practice Address - Country:US
Practice Address - Phone:253-389-5302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60253810225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist