Basic Information
| Provider Information | |||||||||
| NPI: | 1033413562 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACAYO DETTBARN | ||||||||
| FirstName: | GISELLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LACAYO DETTBARN | ||||||||
| OtherFirstName: | GISELLA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9333 SW 152ND ST | ||||||||
| Address2: | |||||||||
| City: | PALMETTO BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331571778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052512500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9333 SW 152ND ST | ||||||||
| Address2: | |||||||||
| City: | PALMETTO BAY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331571778 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052512500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/23/2010 | ||||||||
| LastUpdateDate: | 08/04/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN9204956 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | ARNP9204956 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.