Provider Demographics
NPI:1962074062
Name:MATHIEU, LISSA EMMANUELLA (LPN)
Entity type:Individual
Prefix:MS
First Name:LISSA
Middle Name:EMMANUELLA
Last Name:MATHIEU
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 1:1280 E 84TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-4912
Mailing Address - Country:US
Mailing Address - Phone:347-309-3956
Mailing Address - Fax:
Practice Address - Street 1:22121 JAMAICA AVE FL 2
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-2015
Practice Address - Country:US
Practice Address - Phone:718-468-6923
Practice Address - Fax:718-468-6925
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-16
Last Update Date:2021-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY340261164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse