Provider Demographics
NPI:1033413562
Name:LACAYO DETTBARN, GISELLA (CRNA)
Entity Type:Individual
Prefix:
First Name:GISELLA
Middle Name:
Last Name:LACAYO DETTBARN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:GISELLA
Other - Middle Name:
Other - Last Name:LACAYO DETTBARN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:9333 SW 152ND ST
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-1778
Mailing Address - Country:US
Mailing Address - Phone:305-251-2500
Mailing Address - Fax:
Practice Address - Street 1:9333 SW 152ND ST
Practice Address - Street 2:
Practice Address - City:PALMETTO BAY
Practice Address - State:FL
Practice Address - Zip Code:33157-1778
Practice Address - Country:US
Practice Address - Phone:305-251-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-23
Last Update Date:2015-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9204956367500000X
FLARNP9204956367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered