Provider Demographics
NPI:1609475151
Name:LISIAKOWSKI, JILLIAN ROSE (FNP-C)
Entity type:Individual
Prefix:
First Name:JILLIAN
Middle Name:ROSE
Last Name:LISIAKOWSKI
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 MADISON AVE STE 2817
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5101
Mailing Address - Country:US
Mailing Address - Phone:888-553-2823
Mailing Address - Fax:888-553-2823
Practice Address - Street 1:169 MADISON AVE STE 2817
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-5101
Practice Address - Country:US
Practice Address - Phone:888-553-2823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-25
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN245155363LF0000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty