Healthcare Provider Details

I. General information

NPI: 1124301353
Provider Name (Legal Business Name): LISA MARIE CENTER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2011
Last Update Date: 09/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1252 ALBANY ST
SCHENECTADY NY
12304-2702
US

IV. Provider business mailing address

1252 ALBANY ST
SCHENECTADY NY
12304-2702
US

V. Phone/Fax

Practice location:
  • Phone: 518-881-3964
  • Fax: 518-881-3963
Mailing address:
  • Phone: 518-881-3964
  • Fax: 518-881-3963

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number453924
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: