Provider Demographics
NPI:1518504455
Name:CRUZ, GISSELLA CAROLINA
Entity Type:Individual
Prefix:
First Name:GISSELLA
Middle Name:CAROLINA
Last Name:CRUZ
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 1:680 E STATE ROAD 164
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47546-8471
Mailing Address - Country:US
Mailing Address - Phone:812-309-9357
Mailing Address - Fax:
Practice Address - Street 1:966 BARTLEY ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-2641
Practice Address - Country:US
Practice Address - Phone:812-996-7810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28175785A163W00000X
IN71009634A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse