Healthcare Provider Details

I. General information

NPI: 1790732899
Provider Name (Legal Business Name): MARYANN LISAK RN, MS, PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 LAKESIDE AVE SUITE 115
BURLINGTON VT
05401-4939
US

IV. Provider business mailing address

128 LAKESIDE AVE SUITE 115
BURLINGTON VT
05401-4939
US

V. Phone/Fax

Practice location:
  • Phone: 802-860-1928
  • Fax:
Mailing address:
  • Phone: 802-860-1928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1010019912
License Number StateVT
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number101.0019912
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: