Provider Demographics
NPI:1972548014
Name:PALESTRA, LISA LONG (DC)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:LONG
Last Name:PALESTRA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4282 W LINEBAUGH AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33624-5241
Mailing Address - Country:US
Mailing Address - Phone:813-930-6112
Mailing Address - Fax:813-930-6332
Practice Address - Street 1:4282 W LINEBAUGH AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33624-5241
Practice Address - Country:US
Practice Address - Phone:813-930-6112
Practice Address - Fax:813-930-6332
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH6821111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL381816100Medicaid
FL381816100Medicaid
FL55288Medicare ID - Type Unspecified