Provider Demographics
NPI:1053711044
Name:CLEMENT-DEFALCO, LISA (NP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CLEMENT-DEFALCO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 EARLYSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:EARLYSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22936-9561
Mailing Address - Country:US
Mailing Address - Phone:508-725-7382
Mailing Address - Fax:
Practice Address - Street 1:3155 EARLYSVILLE RD
Practice Address - Street 2:
Practice Address - City:EARLYSVILLE
Practice Address - State:VA
Practice Address - Zip Code:22936-9561
Practice Address - Country:US
Practice Address - Phone:508-725-7382
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2014014501363LF0000X
VA0024171905363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily