MEDICARE: MS. LISA S. BLIZZARD SUPPORT COORDINATOR

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1447258066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA S. BLIZZARD SUPPORT COORDINATOR

Provider Business Mailing Address
First Line	:	9526 ARGYLE FOREST BLVD
Second Line	:	SUITE B2 PMB #309
City	:	JACKSONVILLE
State	:	FL
Zip	:	32222-2825
Country	:	US
Telephone Number	:	904-772-6442
Fax Number	:	904-772-6443

Provider Business Practice Location Address
First Line	:	9447 BRUNTSFIELD DR
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32244-7176
Country	:	US
Telephone Number	:	904-772-6442
Fax Number	:	904-772-6443

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2005
Last Update Date	:	07/09/2007

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