Provider Demographics
NPI:1750742482
Name:MOLLOY, LISA ANNE
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:MOLLOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 LINDA AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-2050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:228 LINDA AVE
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:NY
Practice Address - Zip Code:10532-2050
Practice Address - Country:US
Practice Address - Phone:914-773-7423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2016-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276963-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY276963-1OtherLICENSED PRACTICAL NURSE