Healthcare Provider Details

I. General information

NPI: 1730419862
Provider Name (Legal Business Name): LISA MOORMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2010
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 WORCESTER ST
WEST BOYLSTON MA
01583-1765
US

IV. Provider business mailing address

11 BERRY LN
ACTON MA
01720-5503
US

V. Phone/Fax

Practice location:
  • Phone: 508-835-6666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number254843
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number10947611
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: