Provider Demographics
NPI:1295958205
Name:CLAYTON WILLING, LISA DAWN (LPN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DAWN
Last Name:CLAYTON WILLING
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 1:86 QUEEN DR
Mailing Address - Street 2:
Mailing Address - City:SOUND BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11789-1528
Mailing Address - Country:US
Mailing Address - Phone:631-821-1049
Mailing Address - Fax:
Practice Address - Street 1:86 QUEEN DR
Practice Address - Street 2:
Practice Address - City:SOUND BEACH
Practice Address - State:NY
Practice Address - Zip Code:11789-1528
Practice Address - Country:US
Practice Address - Phone:631-821-1049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266510-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse