Healthcare Provider Details

I. General information

NPI: 1437353273
Provider Name (Legal Business Name): LISA BOULE' CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 08/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2066 RICHMOND AVENUE 1ST FLOOR
STATEN ISLAND NY
10314-3916
US

IV. Provider business mailing address

2066 RICHMOND AVENUE 1ST FLOOR
STATEN ISLAND NY
10314-3916
US

V. Phone/Fax

Practice location:
  • Phone: 718-982-9001
  • Fax: 718-982-9008
Mailing address:
  • Phone: 718-982-9001
  • Fax: 718-982-9008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0024165610
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF381165-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number358860-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: