MEDICARE: LISA DIMONDSTEIN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LW0102X	Women's Health Nurse Practitioner	1010012146	VT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1194777011
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA DIMONDSTEIN NP

Provider Business Mailing Address
First Line	:	PO BOX 347
Second Line	:
City	:	HYDE PARK
State	:	VT
Zip	:	05655-0347
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	213 E MAIN ST
Second Line	:
City	:	HYDE PARK
State	:	VT
Zip	:	05655-9274
Country	:	US
Telephone Number	:	802-888-3077
Fax Number	:	802-888-6912

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	04/26/2012

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