Provider Demographics
NPI:1699263269
Name:DUBE, LYSIANNE PHAM (FNP-C)
Entity type:Individual
Prefix:MS
First Name:LYSIANNE
Middle Name:PHAM
Last Name:DUBE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:MS
Other - First Name:MARY-LYSIANNE
Other - Middle Name:VAN
Other - Last Name:PHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1305 BLANCO TRL
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-1856
Mailing Address - Country:US
Mailing Address - Phone:858-225-9525
Mailing Address - Fax:
Practice Address - Street 1:2201 HERITAGE PKWY STE 111
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5628
Practice Address - Country:US
Practice Address - Phone:817-472-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-28
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008968363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care