Provider Demographics
NPI:1386130110
Name:FONSECA, LISA M
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:FONSECA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98-857 IHO PL APT B
Mailing Address - Street 2:
Mailing Address - City:AIEA
Mailing Address - State:HI
Mailing Address - Zip Code:96701-2605
Mailing Address - Country:US
Mailing Address - Phone:808-488-1014
Mailing Address - Fax:
Practice Address - Street 1:1441 PALI HWY
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96813-2050
Practice Address - Country:US
Practice Address - Phone:281-844-7577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-04
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator