Provider Demographics
NPI:1104177161
Name:COLBERT, LISA (RN)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:COLBERT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 MT VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:TUPPER LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12986-1812
Mailing Address - Country:US
Mailing Address - Phone:518-359-8440
Mailing Address - Fax:
Practice Address - Street 1:17 MT VIEW AVE
Practice Address - Street 2:
Practice Address - City:TUPPER LAKE
Practice Address - State:NY
Practice Address - Zip Code:12986-1812
Practice Address - Country:US
Practice Address - Phone:518-359-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-30
Last Update Date:2012-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY22564669163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse