Provider Demographics
NPI:1316363161
Name:YOUR FAMILY WALK-IN CLINIC
Entity type:Organization
Organization Name:YOUR FAMILY WALK-IN CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC OWNER/ MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:BRUNTON COOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C, PMHS-C
Authorized Official - Phone:813-792-8555
Mailing Address - Street 1:17929 HUNTING BOW CIRCLE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-8400
Mailing Address - Country:US
Mailing Address - Phone:813-792-8555
Mailing Address - Fax:
Practice Address - Street 1:17929 HUNTING BOW CIR
Practice Address - Street 2:101
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2776972363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty