Healthcare Provider Details

I. General information

NPI: 1740969948
Provider Name (Legal Business Name): LIZABETH GILLESPIE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2023
Last Update Date: 07/14/2023
Certification Date: 07/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 S FAIRMONT AVE STE 230
LODI CA
95240-5142
US

IV. Provider business mailing address

PO BOX 1090
LODI CA
95241-1090
US

V. Phone/Fax

Practice location:
  • Phone: 209-334-4924
  • Fax: 209-334-0127
Mailing address:
  • Phone: 209-334-1800
  • Fax: 209-334-2416

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number8720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: