Provider Demographics
NPI:1841289212
Name:BRENGOLA, LISA DONDERO (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DONDERO
Last Name:BRENGOLA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DONDERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:425 REVERE ST
Mailing Address - Street 2:
Mailing Address - City:REVERE
Mailing Address - State:MA
Mailing Address - Zip Code:02151-4543
Mailing Address - Country:US
Mailing Address - Phone:781-286-1313
Mailing Address - Fax:781-286-1098
Practice Address - Street 1:425 REVERE ST
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-4543
Practice Address - Country:US
Practice Address - Phone:781-286-1313
Practice Address - Fax:781-286-1098
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA215851363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0338290Medicaid
MA0338290Medicaid
P56179Medicare UPIN