Healthcare Provider Details

I. General information

NPI: 1992668735
Provider Name (Legal Business Name): LISA ANN BREWER RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2025
Last Update Date: 12/08/2025
Certification Date: 12/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 LEAVER DR
PALM COAST FL
32137-9749
US

IV. Provider business mailing address

62 LEAVER DR
PALM COAST FL
32137-9749
US

V. Phone/Fax

Practice location:
  • Phone: 304-590-0033
  • Fax:
Mailing address:
  • Phone: 304-590-0033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License NumberRN9542915
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: