Provider Demographics
NPI:1437892981
Name:COSSABOON, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:COSSABOON
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 1:134 BRIDGETON PIKE STE C
Mailing Address - Street 2:
Mailing Address - City:MULLICA HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08062-2616
Mailing Address - Country:US
Mailing Address - Phone:856-507-2783
Mailing Address - Fax:
Practice Address - Street 1:372 EGG HARBOR RD STE 4A
Practice Address - Street 2:
Practice Address - City:SEWELL
Practice Address - State:NJ
Practice Address - Zip Code:08080-1988
Practice Address - Country:US
Practice Address - Phone:856-218-5900
Practice Address - Fax:856-497-5207
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-13
Last Update Date:2025-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01294300363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily