Healthcare Provider Details

I. General information

NPI: 1518910322
Provider Name (Legal Business Name): LISA RENEE MUTH A.R.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7900 BELFORT PKWY SUITE 300
JACKSONVILLE FL
32256-6931
US

IV. Provider business mailing address

3355 CLAIRE LN #1604
JACKSONVILLE FL
32223-6677
US

V. Phone/Fax

Practice location:
  • Phone: 904-281-0107
  • Fax: 904-281-0788
Mailing address:
  • Phone: 904-880-1496
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP2218732
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: