Healthcare Provider Details

I. General information

NPI: 1871581660
Provider Name (Legal Business Name): LOLITA CONDINO MASSENGILL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6665 BANBURY ROAD
JACKSONVILLE FL
32211
US

IV. Provider business mailing address

4850 MOTOR YACHT DR
JACKSONVILLE FL
32225-4029
US

V. Phone/Fax

Practice location:
  • Phone: 904-745-9333
  • Fax: 904-743-0046
Mailing address:
  • Phone: 904-565-1641
  • Fax: 904-996-0691

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberARNP2007072
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: