Healthcare Provider Details

I. General information

NPI: 1871863324
Provider Name (Legal Business Name): GINA M LISBERGER R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GINA M CINQUEMANI R.N.

II. Dates (important events)

Enumeration Date: 12/30/2011
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3251 ROUTE 112 BLDG. 9/SUITE 2
MEDFORD NY
11763-1446
US

IV. Provider business mailing address

7 SEAFIELD LN
WESTHAMPTON BEACH NY
11978-2714
US

V. Phone/Fax

Practice location:
  • Phone: 631-451-6007
  • Fax: 631-297-8121
Mailing address:
  • Phone: 631-288-1113
  • Fax: 631-730-1020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number630514
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number630514-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: