Healthcare Provider Details

I. General information

NPI: 1205439023
Provider Name (Legal Business Name): LISA M DILIBERTO RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2020
Last Update Date: 11/17/2020
Certification Date: 11/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 DRIVING PARK AVE 2ND FLOOR
NEWARK NY
14513-1090
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 315-359-2670
  • Fax: 315-359-2675
Mailing address:
  • Phone: 315-359-2670
  • Fax: 315-359-2675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number617682
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: