Provider Demographics
NPI:1356706964
Name:FETCHKO, LISA JOY (MSNED, RN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JOY
Last Name:FETCHKO
Suffix:
Gender:F
Credentials:MSNED, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 PRIMROSE PL
Mailing Address - Street 2:
Mailing Address - City:DELRAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08075-2818
Mailing Address - Country:US
Mailing Address - Phone:609-781-5627
Mailing Address - Fax:856-461-8138
Practice Address - Street 1:23 PRIMROSE PL
Practice Address - Street 2:
Practice Address - City:DELRAN
Practice Address - State:NJ
Practice Address - Zip Code:08075-2818
Practice Address - Country:US
Practice Address - Phone:609-781-5627
Practice Address - Fax:856-461-8138
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-24
Last Update Date:2015-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR11111900163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management