Healthcare Provider Details

I. General information

NPI: 1609535376
Provider Name (Legal Business Name): LISA DAWN GIBBS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 12/10/2021
Certification Date: 12/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 FAIRMONT DR
SAN LEANDRO CA
94578-1001
US

IV. Provider business mailing address

4115 RAVENWOOD PL
CASTRO VALLEY CA
94546-6015
US

V. Phone/Fax

Practice location:
  • Phone: 510-895-5502
  • Fax: 510-895-7407
Mailing address:
  • Phone: 510-329-5335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number814892
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: