1952569436 NPI number — MRS. LISA M MANDELL PA

Table of content: MRS. LISA M MANDELL PA (NPI 1952569436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952569436 NPI number — MRS. LISA M MANDELL PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANDELL
Provider First Name:
LISA
Provider Middle Name:
M
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HERZ
Provider Other First Name:
LISA
Provider Other Middle Name:
M
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1952569436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5590 KIETZKE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RENO
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89511-3019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
775-323-2080
Provider Business Mailing Address Fax Number:
775-657-9881

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 PRINGLE WAY
Provider Second Line Business Practice Location Address:
SUITE 1007
Provider Business Practice Location Address City Name:
RENO
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89502-1464
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
775-323-2080
Provider Business Practice Location Address Fax Number:
775-657-9881
Provider Enumeration Date:
05/30/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA1094 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)