Basic Information
| Provider Information | |||||||||
| NPI: | 1841289212 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRENGOLA | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | DONDERO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DONDERO | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 425 REVERE ST | ||||||||
| Address2: | |||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021514543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812861313 | ||||||||
| FaxNumber: | 7812861098 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 REVERE ST | ||||||||
| Address2: | |||||||||
| City: | REVERE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021514543 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7812861313 | ||||||||
| FaxNumber: | 7812861098 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2005 | ||||||||
| LastUpdateDate: | 04/04/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 215851 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0338290 | 05 | MA | MEDICAID |