Provider Demographics
NPI:1316416076
Name:BRYAN UKAWUILULU, LISA TRACY ANN (APRN)
Entity Type:Individual
Prefix:
First Name:LISA TRACY ANN
Middle Name:
Last Name:BRYAN UKAWUILULU
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5418 FAN PALM CT
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-7447
Mailing Address - Country:US
Mailing Address - Phone:386-214-5004
Mailing Address - Fax:
Practice Address - Street 1:405 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2730
Practice Address - Country:US
Practice Address - Phone:386-506-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-23
Last Update Date:2018-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9282094363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner