Healthcare Provider Details

I. General information

NPI: 1376478891
Provider Name (Legal Business Name): MANDI LYNNE TIMOTHY FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19009 FERN MEADOW LOOP
LUTZ FL
33558-4001
US

IV. Provider business mailing address

19009 FERN MEADOW LOOP
LUTZ FL
33558-4001
US

V. Phone/Fax

Practice location:
  • Phone: 208-750-5747
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11045664
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: