Provider Demographics
NPI:1285878157
Name:MARINER, LESA W (ARNP)
Entity type:Individual
Prefix:
First Name:LESA
Middle Name:W
Last Name:MARINER
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 1:1014 E. NORTH BLVD, HWY441
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748
Mailing Address - Country:US
Mailing Address - Phone:352-326-5254
Mailing Address - Fax:353-326-5402
Practice Address - Street 1:1014 E. NORTH BLVD, HWY441
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748
Practice Address - Country:US
Practice Address - Phone:352-326-5254
Practice Address - Fax:353-326-5402
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9271409364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health