Provider Demographics
NPI:1124562277
Name:GANDOLFO, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GANDOLFO
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 1:1139 CONEY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-2305
Mailing Address - Country:US
Mailing Address - Phone:718-724-1730
Mailing Address - Fax:718-724-1735
Practice Address - Street 1:1139 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-2305
Practice Address - Country:US
Practice Address - Phone:718-724-1730
Practice Address - Fax:718-724-1735
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA387742-1163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool