Healthcare Provider Details

I. General information

NPI: 1366922460
Provider Name (Legal Business Name): LISA RUGGIERO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 02/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 HOLLAND ST
SOMERVILLE MA
02144-2705
US

IV. Provider business mailing address

38 1ST ST
MELROSE MA
02176-4011
US

V. Phone/Fax

Practice location:
  • Phone: 617-629-6350
  • Fax:
Mailing address:
  • Phone: 781-492-4867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberRN2286845
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: