Healthcare Provider Details

I. General information

NPI: 1447420195
Provider Name (Legal Business Name): LISA LYNN EGNACZYK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

166 GARMON AVE
OLD FORGE NY
13420-0295
US

IV. Provider business mailing address

166 GARMON AVE PO BOX 295
OLD FORGE NY
13420-0295
US

V. Phone/Fax

Practice location:
  • Phone: 315-369-5007
  • Fax:
Mailing address:
  • Phone: 315-369-5007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number593804-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: