Provider Demographics
NPI:1760742449
Name:GONSALVES, LISA DIANE (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DIANE
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12384 SARATOGA SUNNYVALE RD
Mailing Address - Street 2:
Mailing Address - City:SARATOGA
Mailing Address - State:CA
Mailing Address - Zip Code:95070-3084
Mailing Address - Country:US
Mailing Address - Phone:408-996-2180
Mailing Address - Fax:
Practice Address - Street 1:12384 SARATOGA SUNNYVALE RD
Practice Address - Street 2:
Practice Address - City:SARATOGA
Practice Address - State:CA
Practice Address - Zip Code:95070-3084
Practice Address - Country:US
Practice Address - Phone:408-996-2180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-29
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA770890163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse