Provider Demographics
NPI:1801363411
Name:ANTONCZAK, LISA ANN (APRN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:ANTONCZAK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:THUMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:23 PEPPERWOOD CT
Mailing Address - Street 2:
Mailing Address - City:BOYNTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33426-9351
Mailing Address - Country:US
Mailing Address - Phone:330-717-4013
Mailing Address - Fax:
Practice Address - Street 1:23 PEPPERWOOD CT
Practice Address - Street 2:
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-9351
Practice Address - Country:US
Practice Address - Phone:330-717-4013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-01
Last Update Date:2023-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1000002207Q00000X
FLAPRN11000002363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine