Provider Demographics
NPI:1750154662
Name:GAILLIARD, LISA (RN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GAILLIARD
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 1:103 E 125TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035-0776
Mailing Address - Country:US
Mailing Address - Phone:646-320-1786
Mailing Address - Fax:
Practice Address - Street 1:103 E 125TH ST FL 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035-0776
Practice Address - Country:US
Practice Address - Phone:646-320-1786
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-02
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY461778-01163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)