Provider Information for 1972170926
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LISA MARIE YOUNG
Sex: Female
NPI: 1972170926
Last Updated: 2022-08-12
Certification Date: 2022-08-12
Certification Date: 2022-08-12
Details
| Name | Value | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1972170926 | ||||||||||||
| Enumeration Date | 2021-06-08 | ||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||
| Sole Proprietor | YES | ||||||||||||
| Status | Active | ||||||||||||
| Mailing Address | 3270 FRESNO AVE SE PALM BAY, FL 32909-8348 United States Phone: 321-591-4551 | Fax: | ||||||||||||
| Primary Practice Address | 3270 FRESNO AVE SE PALM BAY, FL 32909-8348 United States Phone: 321-591-4551 | Fax: | ||||||||||||
| Secondary Practice Address(es) | 725 N 12TH AVE BLDG B | ||||||||||||
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