Healthcare Provider Details

I. General information

NPI: 1417596883
Provider Name (Legal Business Name): LYNNE MARIE BUSTRAAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2020
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 W UNDERWOOD ST
ORLANDO FL
32806-1110
US

IV. Provider business mailing address

2700 N PENINSULA AVE APT 425
NEW SMYRNA BEACH FL
32169-2079
US

V. Phone/Fax

Practice location:
  • Phone: 407-843-7165
  • Fax:
Mailing address:
  • Phone: 407-221-4914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberAPRN2689732
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: