Provider Demographics
NPI:1710375183
Name:LOLLIE, CINDY
Entity Type:Individual
Prefix:
First Name:CINDY
Middle Name:
Last Name:LOLLIE
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 1:17994 NE SR 69
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1071
Mailing Address - Country:US
Mailing Address - Phone:850-674-1025
Mailing Address - Fax:
Practice Address - Street 1:17994 NE SR 69
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1071
Practice Address - Country:US
Practice Address - Phone:850-674-1025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL12601310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility