Healthcare Provider Details

I. General information

NPI: 1164040259
Provider Name (Legal Business Name): ANNET TAMARA LISTER PEREZ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2020
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 DEL PRADO BLVD S STE 303
CAPE CORAL FL
33904-7222
US

IV. Provider business mailing address

1123 SE 19TH LN
CAPE CORAL FL
33990-4532
US

V. Phone/Fax

Practice location:
  • Phone: 239-317-0265
  • Fax: 239-673-7681
Mailing address:
  • Phone: 305-572-3747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number11007889
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPRN110078
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: