Provider Demographics
NPI:1063611655
Name:WALZ, LISA FRANCES (LPN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:FRANCES
Last Name:WALZ
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SHELDON DR
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-4817
Mailing Address - Country:US
Mailing Address - Phone:914-729-4066
Mailing Address - Fax:845-849-2487
Practice Address - Street 1:7 SHELDON DR
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-4817
Practice Address - Country:US
Practice Address - Phone:914-729-4066
Practice Address - Fax:845-849-2487
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282227-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02842244Medicaid