Provider Demographics
NPI:1023287471
Name:PEZZULLO, LISA KAREN (CRTT)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:KAREN
Last Name:PEZZULLO
Suffix:
Gender:F
Credentials:CRTT
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:KAREN
Other - Last Name:PEZZULLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10547 SW SUNRAY ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-7721
Mailing Address - Country:US
Mailing Address - Phone:954-649-4587
Mailing Address - Fax:727-674-1816
Practice Address - Street 1:10547 SW SUNRAY ST
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-7721
Practice Address - Country:US
Practice Address - Phone:954-649-4587
Practice Address - Fax:727-674-1816
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTT8731227800000X, 2278H0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278H0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedHome Health
No227800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Certified
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012962100Medicaid