Provider Demographics
NPI:1962681460
Name:MCCORDIC, LISA (RNCS)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MCCORDIC
Suffix:
Gender:F
Credentials:RNCS
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:LUCZKOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CS
Mailing Address - Street 1:151 MYSTIC AVE
Mailing Address - Street 2:SUITE SIX
Mailing Address - City:MEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02155-4632
Mailing Address - Country:US
Mailing Address - Phone:781-396-1199
Mailing Address - Fax:781-396-1439
Practice Address - Street 1:151 MYSTIC AVE
Practice Address - Street 2:SUITE SIX
Practice Address - City:MEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02155-4632
Practice Address - Country:US
Practice Address - Phone:781-396-1199
Practice Address - Fax:781-396-1439
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA178205163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAPN0723OtherBLUE CROSS
MANS0447Medicare PIN