Healthcare Provider Details

I. General information

NPI: 1174566079
Provider Name (Legal Business Name): LISA ROMARD PNP.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 07/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STONY BROOK CHILDRENS HOSPITAL T-11, RM 080
STONY BROOK NY
11794-8111
US

IV. Provider business mailing address

101 NICOLLS RD
STONY BROOK NY
11794-8111
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-8340
  • Fax:
Mailing address:
  • Phone: 631-444-8340
  • Fax: 631-444-6045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberF381249
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: