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Provider Information for 1316405996

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: 1316405996

Calendar   Last Updated:  2021-10-12
  Certification Date:  2021-10-12


Name Value
NPI 1316405996
Enumeration Date 2019-03-04
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 11144 ANCIENT FUTURES DR
TAMPA, FL 33647-3577
United States

Phone: 586-291-9457 | Fax:
View Map External Link
Primary Practice Address 10150 HIGHLAND MANOR DR STE 240
TAMPA, FL 33610-9750
United States

Phone: 813-259-1013 | Fax: 813-254-0396
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Secondary Practice Address 50258 VAN DYKE AVE STE A
SHELBY TWP, MI 48317-1374
United States

Phone: 586-884-4714 | Fax:
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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 363LF0000X - Nurse Practitioner Family FL APRN11007252
No 363LF0000X - Nurse Practitioner Family MI 4704263793