Provider Demographics
NPI:1184029761
Name:SALVADOR, LUCILITA
Entity Type:Individual
Prefix:
First Name:LUCILITA
Middle Name:
Last Name:SALVADOR
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 1:20008 NE BURNS AVE
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1028
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11064 NW DEMPSEY BARRON RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:FL
Practice Address - Zip Code:32321-2622
Practice Address - Country:US
Practice Address - Phone:850-643-9658
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-25
Last Update Date:2014-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9100848363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant