Provider Demographics
NPI:1962577361
Name:ANTONELLI, LISA M (APRN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:ANTONELLI
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:266 RINDGE AVE # B
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02140-3202
Mailing Address - Country:US
Mailing Address - Phone:617-665-3340
Mailing Address - Fax:
Practice Address - Street 1:266 RINDGE AVE # B
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02140-3202
Practice Address - Country:US
Practice Address - Phone:617-665-3340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA87024363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP1476OtherBCBS MA
MAUX9788Medicare PIN
MANP1476OtherBCBS MA