Provider Demographics
NPI:1720655582
Name:WISTLING, LORI L (APRN)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:L
Last Name:WISTLING
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 1:12220 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-2631
Mailing Address - Country:US
Mailing Address - Phone:352-556-5216
Mailing Address - Fax:
Practice Address - Street 1:12220 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-2631
Practice Address - Country:US
Practice Address - Phone:352-556-5216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-09
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11013486363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily