Healthcare Provider Details

I. General information

NPI: 1801084751
Provider Name (Legal Business Name): LISA ELLEN JACAVONE RN/NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 CHALKSTONE AVE
PROVIDENCE RI
02908-4734
US

IV. Provider business mailing address

830 CHALKSTONE AVE
PROVIDENCE RI
02908-4734
US

V. Phone/Fax

Practice location:
  • Phone: 401-273-7100
  • Fax: 401-459-4797
Mailing address:
  • Phone: 401-273-7100
  • Fax: 401-459-4797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN36765
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberNPP37867
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN01777
License Number StateRI
# 4
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN2274406
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: