Provider Demographics
NPI:1205463114
Name:WHITAKER, LISSETE ARIAS
Entity type:Individual
Prefix:
First Name:LISSETE
Middle Name:ARIAS
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5622 S DENHAM RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77389-1515
Mailing Address - Country:US
Mailing Address - Phone:770-757-8028
Mailing Address - Fax:
Practice Address - Street 1:327 BEACH 19TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-4423
Practice Address - Country:US
Practice Address - Phone:718-869-7672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty