Healthcare Provider Details

I. General information

NPI: 1508086398
Provider Name (Legal Business Name): LISA JOAN DUFFY CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 03/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SOUTH WYOMING AVENUE SUITE 2
EDWARDSVILLE PA
18704
US

IV. Provider business mailing address

75 SOUTH WYOMING AVENUE SUITE 2
EDWARDSVILLE PA
18704
US

V. Phone/Fax

Practice location:
  • Phone: 570-824-2800
  • Fax: 570-718-1476
Mailing address:
  • Phone: 570-824-2800
  • Fax: 570-718-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP006462B
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: