Healthcare Provider Details

I. General information

NPI: 1699453290
Provider Name (Legal Business Name): LISA D PRIETO PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2023
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5753 HIGHWAY 85 N STE 7937
CRESTVIEW FL
32536-9365
US

IV. Provider business mailing address

3206 DEERFIELD POINTE DR
ORANGE PARK FL
32073-1900
US

V. Phone/Fax

Practice location:
  • Phone: 904-460-4470
  • Fax:
Mailing address:
  • Phone: 904-460-4470
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number05250025
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: