Healthcare Provider Details

I. General information

NPI: 1194777011
Provider Name (Legal Business Name): LISA DIMONDSTEIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 04/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 E MAIN ST
HYDE PARK VT
05655-9274
US

IV. Provider business mailing address

PO BOX 347
HYDE PARK VT
05655-0347
US

V. Phone/Fax

Practice location:
  • Phone: 802-888-3077
  • Fax: 802-888-6912
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1010012146
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: