Healthcare Provider Details

I. General information

NPI: 1184307167
Provider Name (Legal Business Name): LIESEL LA FARGE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2023
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 SHERBURNE CMNS
NANTUCKET MA
02554-4451
US

IV. Provider business mailing address

PO BOX 1719
SANDWICH MA
02563-1719
US

V. Phone/Fax

Practice location:
  • Phone: 774-333-3933
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN2338728
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: