Healthcare Provider Details

I. General information

NPI: 1063539617
Provider Name (Legal Business Name): LISA DOOLITTLE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 JEFFERSON ST
PHOENIX NY
13135-2333
US

IV. Provider business mailing address

348 LAKE RD
OSWEGO NY
13126-5974
US

V. Phone/Fax

Practice location:
  • Phone: 315-349-7963
  • Fax: 315-349-7696
Mailing address:
  • Phone: 315-349-7963
  • Fax: 315-349-7696

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF302052
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: