Healthcare Provider Details

I. General information

NPI: 1043603459
Provider Name (Legal Business Name): LISA HA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2015
Last Update Date: 01/22/2022
Certification Date: 01/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE
HACKENSACK NJ
07601-1997
US

IV. Provider business mailing address

20 PROSPECT AVE
HACKENSACK NJ
07601-1997
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number669305
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR19896800
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number007470
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberF430992
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number26NJ00902400
License Number StateNJ

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: