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Provider Information for 1104327790

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: FEMALE

Individual NPI: 1104327790

Calendar   Last Updated:  2019-10-02
  Certification Date: 


Name Value
NPI 1104327790
Enumeration Date 2018-02-28
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 38135 MARKET SQ
ZEPHYRHILLS, FL 33542-7505
United States

Phone: 352-567-0188 | Fax: 813-355-5101
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Primary Practice Address 2352 BRUCE B DOWNS BLVD STE 102
WESLEY CHAPEL, FL 33544-9203
United States

Phone: 813-979-0440 | Fax: 813-355-5054
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Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 363A00000X - Physician Assistant FL PA91100901