Provider Demographics
NPI:1144398165
Name:LUST, LISA M (DC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
Last Name:LUST
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:LUST-STEWART
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:526 SE DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:FL
Mailing Address - Zip Code:34994-3045
Mailing Address - Country:US
Mailing Address - Phone:772-288-2527
Mailing Address - Fax:772-288-2552
Practice Address - Street 1:526 SE DIXIE HWY
Practice Address - Street 2:
Practice Address - City:STUART
Practice Address - State:FL
Practice Address - Zip Code:34994-3045
Practice Address - Country:US
Practice Address - Phone:772-288-2527
Practice Address - Fax:772-288-2552
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006009111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU25971Medicare UPIN
FL22500Medicare PIN