Provider Demographics
NPI:1699592451
Name:SPRAGUE, LISA (LPN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SPRAGUE
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 1:299 HIGHBRIDGE ST APT 21
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1957
Mailing Address - Country:US
Mailing Address - Phone:131-540-9518
Mailing Address - Fax:
Practice Address - Street 1:299 HIGHBRIDGE ST APT 21
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1957
Practice Address - Country:US
Practice Address - Phone:131-540-9518
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY262575164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse