Healthcare Provider Details

I. General information

NPI: 1487171740
Provider Name (Legal Business Name): LISA LIBONATI FNP-BC, APRN, MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 11/15/2021
Certification Date: 11/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8260 GLADIOLUS DR
FORT MYERS FL
33908-4156
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-437-5755
  • Fax: 239-437-5776
Mailing address:
  • Phone: 239-343-3727
  • Fax: 239-343-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number633467
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number344795
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11005466
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11005466
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: