Provider Demographics
NPI:1215767660
Name:LISBON, GABRIELLE ALEXIS
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:ALEXIS
Last Name:LISBON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S WEST CROWN POINT RD STE 120
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-2916
Mailing Address - Country:US
Mailing Address - Phone:407-297-8408
Mailing Address - Fax:407-297-8409
Practice Address - Street 1:301 S WEST CROWN POINT RD STE 120
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-2916
Practice Address - Country:US
Practice Address - Phone:407-297-8408
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-01
Last Update Date:2024-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11034463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily