Healthcare Provider Details

I. General information

NPI: 1700482866
Provider Name (Legal Business Name): LISA MARIE KOUMOULOS APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2020
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 SUMMIT AVE
HACKENSACK NJ
07601-1263
US

IV. Provider business mailing address

92 SUMMIT AVE
HACKENSACK NJ
07601-1263
US

V. Phone/Fax

Practice location:
  • Phone: 201-342-0066
  • Fax:
Mailing address:
  • Phone: 551-206-8615
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ01081600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: