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General NPI Number Information
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NPI Number | 1174840367
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Entity Type | Individual
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Provider Name | LISSA BOILEAU
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Gender | Female
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Dates
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Enumeration Date | 04/27/2010
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Last Update Date | 04/20/2026
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Provider Practice Location Address
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Address Line | 2 THE PLZ
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City | RONKONKOMA
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State | NY
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Zip | 11779-5849
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Country | US
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Telephone | 631-676-2765
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Fax |
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Provider Business Mailing Address
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Address Line | 2100 NESCONSET HWY # 1060
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City | STONY BROOK
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State | NY
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Zip | 11790-3503
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Country | US
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Telephone | 646-789-5877
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Fax | 888-253-5730
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 22609284
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 406771
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License Number State | NY
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