Provider Demographics
NPI:1033499876
Name:SGAMBELLONE, LISA K (CNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:SGAMBELLONE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:K
Other - Last Name:KIDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:629 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:BUCYRUS
Mailing Address - State:OH
Mailing Address - Zip Code:44820-1821
Mailing Address - Country:US
Mailing Address - Phone:419-562-4677
Mailing Address - Fax:419-462-5372
Practice Address - Street 1:629 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:BUCYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820-1821
Practice Address - Country:US
Practice Address - Phone:419-562-4677
Practice Address - Fax:419-462-5372
Is Sole Proprietor?:No
Enumeration Date:2011-08-25
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2011007376363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner