Provider Demographics
NPI:1194777011
Name:DIMONDSTEIN, LISA (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DIMONDSTEIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 347
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:VT
Mailing Address - Zip Code:05655-0347
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:213 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:VT
Practice Address - Zip Code:05655-9274
Practice Address - Country:US
Practice Address - Phone:802-888-3077
Practice Address - Fax:802-888-6912
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT1010012146363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT4000013Medicaid
VTS58865Medicare UPIN
VTNP1212Medicare ID - Type UnspecifiedMEDICARE