Provider Demographics
NPI:1063725422
Name:LISIECKI, EVELYN FABIOLA (PN140320MIV)
Entity type:Individual
Prefix:
First Name:EVELYN
Middle Name:FABIOLA
Last Name:LISIECKI
Suffix:
Gender:F
Credentials:PN140320MIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1024 COLONIAL AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-6925
Mailing Address - Country:US
Mailing Address - Phone:740-223-3414
Mailing Address - Fax:
Practice Address - Street 1:1024 COLONIAL AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6925
Practice Address - Country:US
Practice Address - Phone:740-223-3414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2010-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN140320MIV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse