Provider Demographics
NPI:1174279673
Name:GUBICZA, LISA CLENDENNEN
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:CLENDENNEN
Last Name:GUBICZA
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 1:3104 DAINGERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8988
Mailing Address - Country:US
Mailing Address - Phone:919-819-0023
Mailing Address - Fax:
Practice Address - Street 1:3104 DAINGERFIELD DR
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27616-8988
Practice Address - Country:US
Practice Address - Phone:919-819-0023
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102234163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management