Provider Demographics
NPI:1619541398
Name:MABAYA, RAISSA PRISCA (FNP-BC)
Entity type:Individual
Prefix:
First Name:RAISSA
Middle Name:PRISCA
Last Name:MABAYA
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4406 S FLORIDA AVE STE 17
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2182
Mailing Address - Country:US
Mailing Address - Phone:888-646-5088
Mailing Address - Fax:
Practice Address - Street 1:4406 S FLORIDA AVE STE 17
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2182
Practice Address - Country:US
Practice Address - Phone:888-646-5088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2025-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180342363LF0000X
FLAPRN11023022363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily