Healthcare Provider Details

I. General information

NPI: 1326799750
Provider Name (Legal Business Name): LISA FIRESTONE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2022
Last Update Date: 01/18/2022
Certification Date: 01/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 GRIDER ST
BUFFALO NY
14215-3098
US

IV. Provider business mailing address

462 GRIDER ST
BUFFALO NY
14215-3098
US

V. Phone/Fax

Practice location:
  • Phone: 716-898-6290
  • Fax: 716-898-1953
Mailing address:
  • Phone: 716-898-6290
  • Fax: 716-898-1953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number682204
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: