Provider Demographics
NPI:1255053575
Name:ESPEJO, LANIE
Entity type:Individual
Prefix:
First Name:LANIE
Middle Name:
Last Name:ESPEJO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28639 TRANQUIL LAKE CIR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33543-6593
Mailing Address - Country:US
Mailing Address - Phone:408-704-0028
Mailing Address - Fax:
Practice Address - Street 1:28639 TRANQUIL LAKE CIR
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33543-6593
Practice Address - Country:US
Practice Address - Phone:408-704-0028
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-13
Last Update Date:2022-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021845363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty