Provider Demographics
NPI:1932790581
Name:VIVILACQUA, LISA SABRINA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:SABRINA
Last Name:VIVILACQUA
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 1:317 PLEASANT ST APT A
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-1572
Mailing Address - Country:US
Mailing Address - Phone:530-368-3773
Mailing Address - Fax:
Practice Address - Street 1:101 CIRBY HILLS DR
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-4360
Practice Address - Country:US
Practice Address - Phone:916-787-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-27
Last Update Date:2021-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker