Provider Demographics
NPI:1801084751
Name:JACAVONE, LISA ELLEN (RN/NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ELLEN
Last Name:JACAVONE
Suffix:
Gender:F
Credentials:RN/NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 CHALKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02908-4734
Mailing Address - Country:US
Mailing Address - Phone:401-273-7100
Mailing Address - Fax:401-459-4797
Practice Address - Street 1:830 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4734
Practice Address - Country:US
Practice Address - Phone:401-273-7100
Practice Address - Fax:401-459-4797
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-04
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIRN36765163W00000X
RINPP37867363LA2100X
RIAPRN01777363LP2300X
MARN2274406363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIAPRN01777OtherADVANCED PRACTICE REGISTERED NURSE LICENSE
MACNP2274406OtherCERTIFIED NURSE PRACTITIONER