Provider Demographics
NPI:1952990442
Name:HANNIGAN, LYSA MARIE
Entity Type:Individual
Prefix:
First Name:LYSA
Middle Name:MARIE
Last Name:HANNIGAN
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 1:6558 CEDAR AVE
Mailing Address - Street 2:
Mailing Address - City:PENNSAUKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08109-2402
Mailing Address - Country:US
Mailing Address - Phone:609-221-2611
Mailing Address - Fax:
Practice Address - Street 1:525 ROUTE 73 N STE 117
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-3422
Practice Address - Country:US
Practice Address - Phone:856-254-2487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY802-1393246ZA2600X
NJ55-203785-TT-A246ZA2600X
246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical