Healthcare Provider Details

I. General information

NPI: 1548976830
Provider Name (Legal Business Name): LYS MAIKE ICE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2023
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

853 SUNRIDGE POINT DR
SEFFNER FL
33584-5915
US

IV. Provider business mailing address

853 SUNRIDGE POINT DR
SEFFNER FL
33584-5915
US

V. Phone/Fax

Practice location:
  • Phone: 740-538-1100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11012671
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: