Provider Demographics
NPI:1811658503
Name:FITZGIBBONS, MARISELA LIZZETTE (DNP-A, CRNA)
Entity type:Individual
Prefix:MRS
First Name:MARISELA
Middle Name:LIZZETTE
Last Name:FITZGIBBONS
Suffix:
Gender:F
Credentials:DNP-A, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6039 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75206-7243
Mailing Address - Country:US
Mailing Address - Phone:214-476-2581
Mailing Address - Fax:
Practice Address - Street 1:6039 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75206-7243
Practice Address - Country:US
Practice Address - Phone:214-476-2581
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-04
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1065174367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered