Provider Demographics
NPI:1699261511
Name:MICCIO, LISA ANN (LPN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:MICCIO
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 1:764 BIRCHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:DUANESBURG
Mailing Address - State:NY
Mailing Address - Zip Code:12056-4207
Mailing Address - Country:US
Mailing Address - Phone:518-362-6292
Mailing Address - Fax:
Practice Address - Street 1:764 BIRCHWOOD DR
Practice Address - Street 2:
Practice Address - City:DUANESBURG
Practice Address - State:NY
Practice Address - Zip Code:12056-4207
Practice Address - Country:US
Practice Address - Phone:518-362-6292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY165690-1164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse