Healthcare Provider Details

I. General information

NPI: 1104761212
Provider Name (Legal Business Name): LISA FAY HEARN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2026
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12720 E US HIGHWAY 92
DOVER FL
33527-4138
US

IV. Provider business mailing address

12720 E US HIGHWAY 92
DOVER FL
33527-4138
US

V. Phone/Fax

Practice location:
  • Phone: 813-297-1438
  • Fax: 813-297-1438
Mailing address:
  • Phone: 813-297-1438
  • Fax: 813-297-1438

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number683435396
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: