Provider Demographics
NPI:1528188653
Name:PORCELLO, LISA ANNE (LPN)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANNE
Last Name:PORCELLO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 HERKIMER ST APT 14
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13204-1744
Mailing Address - Country:US
Mailing Address - Phone:315-468-0043
Mailing Address - Fax:
Practice Address - Street 1:2208 BELLEVUE AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13219-3210
Practice Address - Country:US
Practice Address - Phone:315-472-1602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY02201545164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse