Basic Information
| Provider Information | |||||||||
| NPI: | 1316273733 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PERMENTER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7855 ARGYLE FOREST BLVD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322445596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042826331 | ||||||||
| FaxNumber: | 9042824117 | ||||||||
| Practice Location | |||||||||
| Address1: | 11555 CENTRAL PKWY | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322242691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042657755 | ||||||||
| FaxNumber: | 9042657754 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2009 | ||||||||
| LastUpdateDate: | 01/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1457332 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 001566300 | 05 | FL | MEDICAID |