=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770154627
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOTUS HEALTHCARE AND AESTHETICS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2021
-----------------------------------------------------
Last Update Date | 07/01/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 340 W 23RD ST
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-7600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-628-0711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 340 W 23RD ST
-----------------------------------------------------
City | PANAMA CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32405-7600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-628-0711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ APRN
-----------------------------------------------------
Name | MRS. LINDSAY MAY HETRICK
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 850-628-0711
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------