1376016048 NPI number — CHRISTINE SUZANNE LUNDSTEDT FNP-C

Table of content: CHRISTINE SUZANNE LUNDSTEDT FNP-C (NPI 1376016048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376016048 NPI number — CHRISTINE SUZANNE LUNDSTEDT FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LUNDSTEDT
Provider First Name:
CHRISTINE
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376016048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
200 S PARK RD STE 200
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOLLYWOOD
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33021-8541
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-986-2263
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5395 RUFFIN RD STE 204
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92123-1338
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-571-3630
Provider Business Practice Location Address Fax Number:
858-430-3146
Provider Enumeration Date:
01/06/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  95009138 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: 11009616 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 115493600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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