Provider Demographics
NPI:1023232451
Name:VAN BRUNT, LISA MARIE (CPNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:VAN BRUNT
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 FORT WASHINGTON AVENUE
Mailing Address - Street 2:BUILDING IP7
Mailing Address - City:NY
Mailing Address - State:NY
Mailing Address - Zip Code:10032
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:161 FORT WASHINGTON AVE
Practice Address - Street 2:IP7
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3729
Practice Address - Country:US
Practice Address - Phone:212-305-9770
Practice Address - Fax:212-342-5220
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF381121363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics