Healthcare Provider Details

I. General information

NPI: 1639192768
Provider Name (Legal Business Name): LISSA B ANDRAKAKOS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 06/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15757 CRABBS BRANCH WAY
ROCKVILLE MD
20855-2634
US

IV. Provider business mailing address

15757 CRABBS BRANCH WAY
ROCKVILLE MD
20855-2634
US

V. Phone/Fax

Practice location:
  • Phone: 301-670-0358
  • Fax: 301-670-4636
Mailing address:
  • Phone: 301-670-0358
  • Fax: 301-670-4636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR079598
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberR079598
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: