MEDICARE: LISA ANNE YOUNGBLOOD RN NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN481125	CA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	NP11105	CA
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	11011940	FL

General Provider Information

NPI Number	:	1801843941
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA ANNE YOUNGBLOOD RN NP

Provider Business Mailing Address
First Line	:	103 HALF MOON CIR APT C2
Second Line	:
City	:	HYPOLUXO
State	:	FL
Zip	:	33462-5494
Country	:	US
Telephone Number	:	515-381-8825
Fax Number	:

Provider Business Practice Location Address
First Line	:	1055 WILSHIRE BLVD STE 1705
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-5600
Country	:	US
Telephone Number	:	310-871-0670
Fax Number	:	619-667-0815

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	02/03/2023

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