1609630185 NPI number — LISETE ANDRE FNTP

Table of content: LISETE ANDRE FNTP (NPI 1609630185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609630185 NPI number — LISETE ANDRE FNTP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDRE
Provider First Name:
LISETE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNTP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ANDRE CLEARY
Provider Other First Name:
LISETE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNTP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1609630185
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/06/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8021 SEMINOLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19118-3915
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8021 SEMINOLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19118-3915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
917-488-1126
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2024

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: 171400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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