Healthcare Provider Details

I. General information

NPI: 1306263199
Provider Name (Legal Business Name): LISA ANN SHOTYK AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2014
Last Update Date: 03/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 GLASGOW AVE
NEWARK DE
19702-4773
US

IV. Provider business mailing address

21 N KINGSCROFT DR
BEAR DE
19701-1423
US

V. Phone/Fax

Practice location:
  • Phone: 302-836-8350
  • Fax: 302-836-1906
Mailing address:
  • Phone: 302-836-8350
  • Fax: 302-836-1906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberLB-0000288
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: