MEDICARE: YOUR FAMILY WALK-IN CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2776972	FL

General Provider Information

NPI Number	:	1316363161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	YOUR FAMILY WALK-IN CLINIC

Provider Business Mailing Address
First Line	:	17929 HUNTING BOW CIRCLE
Second Line	:	SUITE 101
City	:	LUTZ
State	:	FL
Zip	:	33558-8400
Country	:	US
Telephone Number	:	813-792-8555
Fax Number	:

Provider Business Practice Location Address
First Line	:	17929 HUNTING BOW CIR
Second Line	:	101
City	:	LUTZ
State	:	FL
Zip	:	33558-5378
Country	:	US
Telephone Number	:	813-792-8555
Fax Number	:

Authorized Official
Title or Position	:	CLINIC OWNER/ MANAGER
Name	:	MRS. LISA ANNE BRUNTON COOLEY
Credential	:	FNP-C, PMHS-C
Telephone Number	:	813-792-8555

Provider Enumeration Date	:	03/17/2014
Last Update Date	:	09/24/2015

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