Provider Demographics
NPI:1902079635
Name:FINA, LERA LIV (DO)
Entity Type:Individual
Prefix:DR
First Name:LERA
Middle Name:LIV
Last Name:FINA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LERA
Other - Middle Name:LIV
Other - Last Name:WULLENWEBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22455 FLORA PARKE XING
Mailing Address - Street 2:
Mailing Address - City:FERNANDINA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32034-8000
Mailing Address - Country:US
Mailing Address - Phone:904-572-1884
Mailing Address - Fax:
Practice Address - Street 1:22455 FLORA PARKE XING
Practice Address - Street 2:
Practice Address - City:FERNANDINA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32034-8000
Practice Address - Country:US
Practice Address - Phone:904-572-1884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-02
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA66488208000000X
FLOS 10686208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202IO12485Medicaid