Provider Demographics
NPI:1518138536
Name:GONZALES, LISA MARIE (CNP)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MARIE
Last Name:GONZALES
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4199 PARKMEAD DR
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-3991
Mailing Address - Country:US
Mailing Address - Phone:614-991-4664
Mailing Address - Fax:
Practice Address - Street 1:5650 BLAZER PKWY
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-3562
Practice Address - Country:US
Practice Address - Phone:614-734-8462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-18
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-08018363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health