Basic Information
Provider Information | |||||||||
NPI: | 1720077134 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KENDALL | ||||||||
FirstName: | LISA | ||||||||
MiddleName: | KING | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KING | ||||||||
OtherFirstName: | LISA | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | FNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 703 VIRGINIA ST | ||||||||
Address2: |   | ||||||||
City: | DUNEDIN | ||||||||
State: | FL | ||||||||
PostalCode: | 346986615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7277344000 | ||||||||
FaxNumber: | 7277385037 | ||||||||
Practice Location | |||||||||
Address1: | 703 VIRGINIA ST | ||||||||
Address2: |   | ||||||||
City: | DUNEDIN | ||||||||
State: | FL | ||||||||
PostalCode: | 346986615 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7277344000 | ||||||||
FaxNumber: | 7277385037 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/18/2005 | ||||||||
LastUpdateDate: | 02/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 201503 | NC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | CP000767 | SD | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 9441597 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 101609400 | 05 | FL |   | MEDICAID | D4Z1M | 01 | FL | BCBS | OTHER |