Provider Demographics
NPI:1265709729
Name:JANICKE, LISA M (RN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:JANICKE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1202 TROY SCHENECTADY RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-1095
Mailing Address - Country:US
Mailing Address - Phone:518-640-3416
Mailing Address - Fax:
Practice Address - Street 1:1202 TROY SCHENECTADY RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-1095
Practice Address - Country:US
Practice Address - Phone:518-640-3416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY631729-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse