Healthcare Provider Details

I. General information

NPI: 1265374672
Provider Name (Legal Business Name): LISANDRA MALDONADO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

124 HAINES RD SW
PALM BAY FL
32908-1337
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-7000
  • Fax:
Mailing address:
  • Phone: 954-716-2909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11046564
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: