Healthcare Provider Details

I. General information

NPI: 1780987529
Provider Name (Legal Business Name): MRS. LISA UPSHAW FUENTE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2010
Last Update Date: 01/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 BRUCE B DOWNS BLVD
TAMPA FL
33612-3803
US

IV. Provider business mailing address

13101 BRUCE B DOWNS BLVD
TAMPA FL
33612-3803
US

V. Phone/Fax

Practice location:
  • Phone: 813-974-0602
  • Fax: 813-558-1343
Mailing address:
  • Phone: 813-974-0602
  • Fax: 813-558-1343

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: