Basic Information
| Provider Information | |||||||||
| NPI: | 1962074062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATHIEU | ||||||||
| FirstName: | LISSA | ||||||||
| MiddleName: | EMMANUELLA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LPN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1280 E 84TH ST FL 1 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112364912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3473093956 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 22121 JAMAICA AVE FL 2 | ||||||||
| Address2: | |||||||||
| City: | QUEENS VILLAGE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114282015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184686923 | ||||||||
| FaxNumber: | 7184686925 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2021 | ||||||||
| LastUpdateDate: | 07/16/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 340261 | NY | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.