Provider Demographics
NPI:1770896409
Name:JANTZEN, LISA MARIE (FNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:JANTZEN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 GAETANO LN
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-2345
Mailing Address - Country:US
Mailing Address - Phone:631-921-2728
Mailing Address - Fax:
Practice Address - Street 1:1 KINGS HWY
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-4216
Practice Address - Country:US
Practice Address - Phone:631-348-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY336440363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily