Healthcare Provider Details

I. General information

NPI: 1174719082
Provider Name (Legal Business Name): LAKE MARY FAMILY PHYSICIANS P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 07/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 WILLISTON PARK PT SUITE 2050
LAKE MARY FL
32746-2172
US

IV. Provider business mailing address

910 WILLISTON PARK PT SUITE 2050
LAKE MARY FL
32746-2172
US

V. Phone/Fax

Practice location:
  • Phone: 407-829-8960
  • Fax: 407-829-8978
Mailing address:
  • Phone: 407-829-8960
  • Fax: 407-829-8978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP1103432
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberME88467, ME88578
License Number StateFL

VIII. Authorized Official

Name: MS. LEAH M SUTPHIN
Title or Position: BILLING MANAGER
Credential:
Phone: 407-829-8960