Healthcare Provider Details

I. General information

NPI: 1922520972
Provider Name (Legal Business Name): LISA M. LEDOUX NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2017
Last Update Date: 11/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 MAIN STREET 3RD FL, SUITE C&D
SPRINGFIELD MA
01107-1112
US

IV. Provider business mailing address

280 CHESTNUT STREET 2ND FL
SPRINGFIELD MA
01199-1001
US

V. Phone/Fax

Practice location:
  • Phone: 413-794-5600
  • Fax: 413-794-7297
Mailing address:
  • Phone: 413-794-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN269919
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN269919
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN269919
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: