MEDICARE: MRS. LISA PEARL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WS0200X	School Registered Nurse	563221-1	NY

General Provider Information

NPI Number	:	1053689570
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA PEARL

Provider Business Mailing Address
First Line	:	1 CATHERINE ST
Second Line	:
City	:	FORT ANN
State	:	NY
Zip	:	12827-5039
Country	:	US
Telephone Number	:	518-639-5594
Fax Number	:	518-639-8911

Provider Business Practice Location Address
First Line	:	1 CATHERINE ST
Second Line	:
City	:	FORT ANN
State	:	NY
Zip	:	12827-5039
Country	:	US
Telephone Number	:	518-639-5594
Fax Number	:	518-639-8911

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2011
Last Update Date	:	12/12/2011

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