Provider Demographics
NPI:1790193746
Name:ELLIS, LYNA CAMPO (MD)
Entity Type:Individual
Prefix:DR
First Name:LYNA
Middle Name:CAMPO
Last Name:ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 AVENUE F NE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-4193
Mailing Address - Country:US
Mailing Address - Phone:863-293-1121
Mailing Address - Fax:
Practice Address - Street 1:200 AVENUE F NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881
Practice Address - Country:US
Practice Address - Phone:863-293-1121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-22
Last Update Date:2019-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294388207R00000X
FLME140818207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY294388OtherLICENSE