Provider Demographics
NPI:1023619590
Name:LOOMIS, LISA A (LPN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:LOOMIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2198 US HIGHWAY 20
Mailing Address - Street 2:
Mailing Address - City:NASSAU
Mailing Address - State:NY
Mailing Address - Zip Code:12123-1733
Mailing Address - Country:US
Mailing Address - Phone:413-672-7072
Mailing Address - Fax:
Practice Address - Street 1:2198 US HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:NASSAU
Practice Address - State:NY
Practice Address - Zip Code:12123-1733
Practice Address - Country:US
Practice Address - Phone:413-672-7072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-02
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALN96407164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MALN96401OtherNURSING LICENSE