MEDICARE: LISA RICHARDSON APRN

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	363L00000X	Nurse Practitioner	APRN3165542	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y05WA	OTHER	FL	BCBS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922168491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA RICHARDSON APRN

Provider Business Mailing Address
First Line	:	PO BOX 551308
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32255-1308
Country	:	US
Telephone Number	:	904-493-3333
Fax Number	:	904-493-2222

Provider Business Practice Location Address
First Line	:	1681 EAGLE HARBOR PKWY STE B
Second Line	:
City	:	FLEMING ISLAND
State	:	FL
Zip	:	32003-4819
Country	:	US
Telephone Number	:	904-644-0092
Fax Number	:	904-644-0099

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

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	01/27/2022

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