Provider Demographics
NPI:1932637543
Name:JIMENEZ, LISA JANE (ARNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JANE
Last Name:JIMENEZ
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4119 S ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-6629
Mailing Address - Country:US
Mailing Address - Phone:386-405-8843
Mailing Address - Fax:
Practice Address - Street 1:301 DR CARTER BLVD
Practice Address - Street 2:
Practice Address - City:BUNNELL
Practice Address - State:FL
Practice Address - Zip Code:32110-6212
Practice Address - Country:US
Practice Address - Phone:386-437-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-25
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9290624363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily