Provider Demographics
NPI:1487737417
Name:BROODY, LISA (CRNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BROODY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1088 W BALTIMORE PIKE
Mailing Address - Street 2:SUITE #2208
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-5146
Mailing Address - Country:US
Mailing Address - Phone:610-891-3049
Mailing Address - Fax:610-891-3919
Practice Address - Street 1:1088 W BALTIMORE PIKE
Practice Address - Street 2:SUITE #2208
Practice Address - City:MEDIA
Practice Address - State:PA
Practice Address - Zip Code:19063-5146
Practice Address - Country:US
Practice Address - Phone:610-891-3049
Practice Address - Fax:610-891-3919
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily