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General NPI Number Information
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NPI Number | 1780916916
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Entity Type | Individual
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Provider Name | LISA WYDRA
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Gender | Female
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Dates
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Enumeration Date | 02/15/2010
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Last Update Date | 01/24/2019
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Provider Practice Location Address
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Address Line | 3391 HIGHWAY 35
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City | HAZLET
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State | NJ
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Zip | 07730-1521
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Country | US
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Telephone | 732-888-8299
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Fax |
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Provider Business Mailing Address
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Address Line | 3391 HIGHWAY 35
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City | HAZLET
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State | NJ
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Zip | 07730-1521
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Country | US
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Telephone | 732-888-8299
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Fax |
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 26NJ00285700
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License Number State | NJ
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 26NR09130100
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License Number State | NJ
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