Healthcare Provider Details

I. General information

NPI: 1316041064
Provider Name (Legal Business Name): JENNIFER LYN CULTRERA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 05/02/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N US HIGHWAY 441 SUITE 540
LADY LAKE FL
32159-8975
US

IV. Provider business mailing address

PO BOX 102222 ATTN: CREDENTIAL DEPT
ATLANTA GA
30368-2222
US

V. Phone/Fax

Practice location:
  • Phone: 352-753-9777
  • Fax: 352-753-9781
Mailing address:
  • Phone: 239-432-8331
  • Fax: 813-976-7895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberME104856
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberME104856
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: