Healthcare Provider Details

I. General information

NPI: 1306248182
Provider Name (Legal Business Name): LISA DAWN BOOTH F.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 07/28/2026
Certification Date: 07/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3614 BLANDING BLVD
JACKSONVILLE FL
32210-5241
US

IV. Provider business mailing address

PO BOX 400
JACKSON TN
38302-0400
US

V. Phone/Fax

Practice location:
  • Phone: 904-419-7100
  • Fax:
Mailing address:
  • Phone: 731-422-0213
  • Fax: 731-660-8369

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number19109
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: