Provider Demographics
NPI:1982703914
Name:RAHAIM, LISA R (NP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:RAHAIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GREGORY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:26 EAST RED BANK AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096
Mailing Address - Country:US
Mailing Address - Phone:856-848-4464
Mailing Address - Fax:856-848-8706
Practice Address - Street 1:26 EAST RED BANK AVE
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:NJ
Practice Address - Zip Code:08096
Practice Address - Country:US
Practice Address - Phone:856-848-4464
Practice Address - Fax:856-848-8706
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00017200363L00000X
NJ26N008267700363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0129640Medicaid
NJ0129640Medicaid