Healthcare Provider Details

I. General information

NPI: 1497746853
Provider Name (Legal Business Name): LISA B FIASCONE PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 05/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 NEW DRIFTWAY SUITE 201
SCITUATE MA
02066-4530
US

IV. Provider business mailing address

10 NEW DRIFTWAY SUITE 201
SCITUATE MA
02066-4530
US

V. Phone/Fax

Practice location:
  • Phone: 781-544-1388
  • Fax: 781-544-3396
Mailing address:
  • Phone: 781-544-1388
  • Fax: 781-544-3396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number137051
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0340731
Identifier TypeMEDICAID
Identifier StateMA
Identifier Issuer
# 2
IdentifierNP2425
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: