Healthcare Provider Details

I. General information

NPI: 1215784004
Provider Name (Legal Business Name): LUCNIE CIVIL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2024
Last Update Date: 05/01/2024
Certification Date: 04/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9416 CYPRESS HARBOR DR
GIBSONTON FL
33534-5121
US

IV. Provider business mailing address

9416 CYPRESS HARBOR DR
GIBSONTON FL
33534-5121
US

V. Phone/Fax

Practice location:
  • Phone: 407-754-7897
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11032571
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: