Healthcare Provider Details

I. General information

NPI: 1639454572
Provider Name (Legal Business Name): LISA M RODRIGUES FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA M FARIAS FNP-BC

II. Dates (important events)

Enumeration Date: 10/11/2011
Last Update Date: 10/19/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 ELMWOOD AVE
PROVIDENCE RI
02907-2423
US

IV. Provider business mailing address

110 ELMWOOD AVE
PROVIDENCE RI
02907-2423
US

V. Phone/Fax

Practice location:
  • Phone: 401-300-5757
  • Fax: 401-300-5656
Mailing address:
  • Phone: 401-300-5757
  • Fax: 401-300-5656

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN214014
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN02224
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: