Healthcare Provider Details

I. General information

NPI: 1669569687
Provider Name (Legal Business Name): LYNN L LYBRAND PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5398 PARK STREET NORTH
ST PETERSBURG FL
33709
US

IV. Provider business mailing address

4805 49TH STREET NORTH
ST PETERSBURG FL
33709
US

V. Phone/Fax

Practice location:
  • Phone: 727-544-1441
  • Fax: 727-545-8263
Mailing address:
  • Phone: 727-526-6624
  • Fax: 727-545-8263

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9101198
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: