Healthcare Provider Details

I. General information

NPI: 1215873161
Provider Name (Legal Business Name): LISA ANTOINETTE FAUNTLEROY REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

10 COMFORT RD
WILLIAMSTOWN NJ
08094-2969
US

IV. Provider business mailing address

10 COMFORT RD
WILLIAMSTOWN NJ
08094-2969
US

V. Phone/Fax

Practice location:
  • Phone: 856-725-6435
  • Fax:
Mailing address:
  • Phone: 856-725-6435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR24051100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: