Provider Demographics
NPI:1760022867
Name:LUNDY, MICHELET
Entity Type:Individual
Prefix:
First Name:MICHELET
Middle Name:
Last Name:LUNDY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 E SENECA AVE APT A
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-6071
Mailing Address - Country:US
Mailing Address - Phone:813-735-7596
Mailing Address - Fax:
Practice Address - Street 1:1018 E SENECA AVE APT A
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-6071
Practice Address - Country:US
Practice Address - Phone:813-735-7596
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL530540814610172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver