Healthcare Provider Details

I. General information

NPI: 1902528581
Provider Name (Legal Business Name): LISA DIANN WALKER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2022
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12271 US HIGHWAY 301 N
PARRISH FL
34219-8410
US

IV. Provider business mailing address

101 RIVERFRONT BLVD STE 710
BRADENTON FL
34205-8812
US

V. Phone/Fax

Practice location:
  • Phone: 941-776-4050
  • Fax:
Mailing address:
  • Phone: 941-776-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11021821
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: