Healthcare Provider Details

I. General information

NPI: 1851372494
Provider Name (Legal Business Name): LAKE PULMONARY CRITICAL CARE P A
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2005
Last Update Date: 01/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1876 NIGHTINGALE LN
TAVARES FL
32778-4359
US

IV. Provider business mailing address

1876 NIGHTINGALE LN
TAVARES FL
32778-4359
US

V. Phone/Fax

Practice location:
  • Phone: 352-742-4447
  • Fax: 352-742-4448
Mailing address:
  • Phone: 352-742-4447
  • Fax: 352-742-4448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SC0200X
TaxonomyCritical Care Medicine Clinical Nurse Specialist
License NumberARNP9218919
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP9218919
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. JESSICA LYNN BARBER
Title or Position: OPERATIONS MANAGER
Credential:
Phone: 352-742-4631