Provider Demographics
NPI:1053747360
Name:PEDOTA, LISA (MS)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:
Last Name:PEDOTA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 BURNEY BLVD
Mailing Address - Street 2:
Mailing Address - City:MASTIC
Mailing Address - State:NY
Mailing Address - Zip Code:11950-1301
Mailing Address - Country:US
Mailing Address - Phone:631-258-0983
Mailing Address - Fax:631-258-0983
Practice Address - Street 1:11 BURNEY BLVD
Practice Address - Street 2:
Practice Address - City:MASTIC
Practice Address - State:NY
Practice Address - Zip Code:11950-1301
Practice Address - Country:US
Practice Address - Phone:631-258-0983
Practice Address - Fax:631-258-0983
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-18
Last Update Date:2016-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator