Provider Demographics
NPI:1770275463
Name:WILTSE, LISA (LAC, DIPLAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILTSE
Suffix:
Gender:F
Credentials:LAC, DIPLAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 NASSAU ST STE 208
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10038-3703
Mailing Address - Country:US
Mailing Address - Phone:620-353-8487
Mailing Address - Fax:212-518-0578
Practice Address - Street 1:43 E 10TH ST APT 6H
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-6106
Practice Address - Country:US
Practice Address - Phone:212-804-7267
Practice Address - Fax:212-518-0578
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY007338-01OtherNY STATE ACUPUNCTURIST LICENSE