Provider Demographics
NPI:1144766619
Name:GISCOMBE, SOPHIA
Entity Type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:GISCOMBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:
Other - Last Name:GISCOMBE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:1841 SW ELIJAH AVE
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-5160
Mailing Address - Country:US
Mailing Address - Phone:561-502-3597
Mailing Address - Fax:561-776-8727
Practice Address - Street 1:840 US HIGHWAY 1 STE 120
Practice Address - Street 2:
Practice Address - City:NORTH PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33408-3858
Practice Address - Country:US
Practice Address - Phone:561-776-7300
Practice Address - Fax:561-776-8727
Is Sole Proprietor?:No
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9338099363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL54-2083748OtherEMPLOYER TAX ID