=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124204227
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NANCY JEAN LISI PTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2008
-----------------------------------------------------
Last Update Date | 01/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 TROWBRIDGE RD SUITE 400
-----------------------------------------------------
City | BOURNE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02532-3660
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-743-0320
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 TER HEUN DR
-----------------------------------------------------
City | FALMOUTH
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02540-2503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-495-7600
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 2426
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------