Provider Demographics
NPI:1417516873
Name:WHITESELL, LISA ANN (MA72926)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:WHITESELL
Suffix:
Gender:F
Credentials:MA72926
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10808 DEERBERRY DR
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-6894
Mailing Address - Country:US
Mailing Address - Phone:727-247-7153
Mailing Address - Fax:
Practice Address - Street 1:5307 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2536
Practice Address - Country:US
Practice Address - Phone:727-900-7788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA72926225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist