Healthcare Provider Details

I. General information

NPI: 1447211818
Provider Name (Legal Business Name): LYNN VAN UMMERSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 IMAGE WAY
ORANGE CITY FL
32763-8399
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 386-774-7411
  • Fax: 386-774-7412
Mailing address:
  • Phone: 239-432-8339
  • Fax: 239-278-3350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number99045
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: