Provider Demographics
NPI:1770782286
Name:BERNDT, LISA LEE (LPN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:LEE
Last Name:BERNDT
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 1:3320 STONEY ST
Mailing Address - Street 2:
Mailing Address - City:MOHEGAN LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10547-1911
Mailing Address - Country:US
Mailing Address - Phone:914-962-3822
Mailing Address - Fax:
Practice Address - Street 1:3320 STONEY ST
Practice Address - Street 2:
Practice Address - City:MOHEGAN LAKE
Practice Address - State:NY
Practice Address - Zip Code:10547-1911
Practice Address - Country:US
Practice Address - Phone:914-962-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274769164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02734678Medicaid