Provider Demographics
NPI:1750554358
Name:EARLYWINE, LISA (CRNA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:EARLYWINE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:TELLINGHUISEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 100254
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0254
Mailing Address - Country:US
Mailing Address - Phone:386-254-4000
Mailing Address - Fax:
Practice Address - Street 1:303 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2709
Practice Address - Country:US
Practice Address - Phone:386-254-4000
Practice Address - Fax:386-231-3695
Is Sole Proprietor?:No
Enumeration Date:2008-04-04
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3200322367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGOtherBCBS
FLPENDINGMedicaid
FL309101500Medicaid
FLAK463ZMedicare PIN
FLPENDINGMedicaid