Basic Information
| Provider Information | |||||||||
| NPI: | 1518281153 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PODLESNY | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | R.N. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 SUNLIGHT LN UNIT 6 | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4105948242 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9730 HEALTHWAY DRIVE | ||||||||
| Address2: | WORCESTER COUNTY HEALTH DEPARTMENT - BERLIN HEALTH CT. | ||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106290164 | ||||||||
| FaxNumber: | 4106290185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2010 | ||||||||
| LastUpdateDate: | 03/25/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | R168158 | MD | Y | Nursing Service Providers | Registered Nurse | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 705371101 | 05 | MD | MEDICAID |