Provider Demographics
NPI:1336860493
Name:LUGO, MIRTA (APRN)
Entity type:Individual
Prefix:
First Name:MIRTA
Middle Name:
Last Name:LUGO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 BELLE TIMBRE AVE
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-7583
Mailing Address - Country:US
Mailing Address - Phone:813-333-8781
Mailing Address - Fax:
Practice Address - Street 1:14254 DR MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:FL
Practice Address - Zip Code:33527-4414
Practice Address - Country:US
Practice Address - Phone:813-653-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-07
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9193993163WC1500X
FLAPRN11021969363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health