Provider Demographics
NPI:1164040259
Name:LISTER PEREZ, ANNET TAMARA (APRN)
Entity type:Individual
Prefix:MRS
First Name:ANNET
Middle Name:TAMARA
Last Name:LISTER PEREZ
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 1:1123 SE 19TH LN
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-4532
Mailing Address - Country:US
Mailing Address - Phone:305-572-3747
Mailing Address - Fax:
Practice Address - Street 1:3501 DEL PRADO BLVD S STE 303
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33904-7222
Practice Address - Country:US
Practice Address - Phone:239-317-0265
Practice Address - Fax:239-673-7681
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-06
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007889207Q00000X
FLAPRN110078363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109138300Medicaid