Provider Demographics
NPI:1073121919
Name:BERNAL CARMONA, LIZANDRA RAMONA
Entity Type:Individual
Prefix:
First Name:LIZANDRA
Middle Name:RAMONA
Last Name:BERNAL CARMONA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28615 FAIRWEATHER DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-5808
Mailing Address - Country:US
Mailing Address - Phone:813-325-7152
Mailing Address - Fax:
Practice Address - Street 1:28615 FAIRWEATHER DR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-5808
Practice Address - Country:US
Practice Address - Phone:813-325-7152
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-16
Last Update Date:2020-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008020363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily