Healthcare Provider Details

I. General information

NPI: 1841289212
Provider Name (Legal Business Name): LISA DONDERO BRENGOLA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA DONDERO

II. Dates (important events)

Enumeration Date: 10/19/2005
Last Update Date: 04/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 REVERE ST
REVERE MA
02151-4543
US

IV. Provider business mailing address

425 REVERE ST
REVERE MA
02151-4543
US

V. Phone/Fax

Practice location:
  • Phone: 781-286-1313
  • Fax: 781-286-1098
Mailing address:
  • Phone: 781-286-1313
  • Fax: 781-286-1098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number215851
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: