Healthcare Provider Details

I. General information

NPI: 1891583274
Provider Name (Legal Business Name): LISA ERTLE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2025
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 PARKER RD STE B
WEST LONG BRANCH NJ
07764-1009
US

IV. Provider business mailing address

687 ELLINGTON RD
RIDGEWOOD NJ
07450-5512
US

V. Phone/Fax

Practice location:
  • Phone: 732-222-0307
  • Fax: 732-222-0394
Mailing address:
  • Phone: 551-482-0173
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15263200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: