Healthcare Provider Details

I. General information

NPI: 1689507063
Provider Name (Legal Business Name): MARY YVONNE FAYE KIERULF LISING OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: YVONNE LISING OD

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 NW 17TH ST
MIAMI FL
33136-1134
US

IV. Provider business mailing address

200 PULITZER DR
HUTTO TX
78634-2317
US

V. Phone/Fax

Practice location:
  • Phone: 800-329-7000
  • Fax: 305-243-5274
Mailing address:
  • Phone: 512-963-7161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: