Provider Demographics
NPI:1154359883
Name:BRUNTON COOLEY, LISA ANNE (APRN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:BRUNTON COOLEY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17929 HUNTING BOW CIR
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-5378
Mailing Address - Country:US
Mailing Address - Phone:813-792-8555
Mailing Address - Fax:
Practice Address - Street 1:17929 HUNTING BOW CIR STE 101
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-5378
Practice Address - Country:US
Practice Address - Phone:813-792-8555
Practice Address - Fax:813-792-0555
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2776972363LP0808X, 363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302641800Medicaid
FL302641800Medicaid