Provider Demographics
NPI:1174498794
Name:DULA LOPEZ, GISSELLE
Entity type:Individual
Prefix:
First Name:GISSELLE
Middle Name:
Last Name:DULA LOPEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GISSELLE
Other - Middle Name:
Other - Last Name:PERDOMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:51 S FRENCH ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22304-4957
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1483 OLD BRIDGE RD # 201
Practice Address - Street 2:
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-2738
Practice Address - Country:US
Practice Address - Phone:703-491-2141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024194950363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner