Basic Information
| Provider Information | |||||||||
| NPI: | 1043986276 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LUNDGREN | ||||||||
| FirstName: | CLAIRE | ||||||||
| MiddleName: | JANICE | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 102222 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303682222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3927482002 | ||||||||
| FaxNumber: | 8134992569 | ||||||||
| Practice Location | |||||||||
| Address1: | 8260 GLADIOLUS DR | ||||||||
| Address2: | |||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 339084156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2394375755 | ||||||||
| FaxNumber: | 2394375776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2021 | ||||||||
| LastUpdateDate: | 08/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 11013708 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 112383800 | 05 | FL | MEDICAID |