Healthcare Provider Details

I. General information

NPI: 1114807112
Provider Name (Legal Business Name): GABRIELLE LYNN DECAESTECKER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2025
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 COLUMBUS AVE
LEBANON OH
45036-8258
US

IV. Provider business mailing address

1425 COLUMBUS AVE
LEBANON OH
45036-8258
US

V. Phone/Fax

Practice location:
  • Phone: 513-282-3010
  • Fax:
Mailing address:
  • Phone: 513-282-3010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.009699RX
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50.009699RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: