Provider Demographics
NPI:1932654381
Name:MARTIN, LISA (ARNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MARTIN
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 1:1718 HAWKSBILL LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34771-7546
Mailing Address - Country:US
Mailing Address - Phone:407-758-6451
Mailing Address - Fax:
Practice Address - Street 1:3712 WINTER GARDEN VINELAND RD
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-5483
Practice Address - Country:US
Practice Address - Phone:407-656-2229
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9283912363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics