Healthcare Provider Details

I. General information

NPI: 1528337144
Provider Name (Legal Business Name): LISA MARIA FERNANDEZ OGNP ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA MARIA QUINONES

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 RODNEY ST
SAINT JAMES NY
11780-1756
US

IV. Provider business mailing address

10 RODNEY ST
SAINT JAMES NY
11780-1756
US

V. Phone/Fax

Practice location:
  • Phone: 631-686-5131
  • Fax:
Mailing address:
  • Phone: 631-686-5131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number396062-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberF301559-1
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License NumberF360270-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: