Provider Demographics
NPI:1871581660
Name:MASSENGILL, LOLITA CONDINO (NP)
Entity type:Individual
Prefix:MS
First Name:LOLITA
Middle Name:CONDINO
Last Name:MASSENGILL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:4850 MOTOR YACHT DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-4029
Mailing Address - Country:US
Mailing Address - Phone:904-565-1641
Mailing Address - Fax:904-996-0691
Practice Address - Street 1:6665 BANBURY ROAD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211
Practice Address - Country:US
Practice Address - Phone:904-745-9333
Practice Address - Fax:904-743-0046
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-06
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2007072363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL300697200Medicaid
FLK0846Medicare ID - Type UnspecifiedPROVIDER #E21812
FL300697200Medicaid