Provider Demographics
NPI:1528076544
Name:MERCURIO, LISA (CPNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:MERCURIO
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MENDELLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:27 FAIRFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:NJ
Mailing Address - Zip Code:07869-1442
Mailing Address - Country:US
Mailing Address - Phone:973-442-5756
Mailing Address - Fax:973-442-5889
Practice Address - Street 1:17 S WARREN ST
Practice Address - Street 2:DOVER COMMUNITY CLINIC
Practice Address - City:DOVER
Practice Address - State:NJ
Practice Address - Zip Code:07801
Practice Address - Country:US
Practice Address - Phone:973-328-3344
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR06262700364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics