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Provider Information for 1528354644

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: 1528354644

Calendar   Last Updated:  2016-11-21
  Certification Date: 


Name Value
NPI 1528354644
Enumeration Date 2011-06-27
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address PO BOX 10744
CLEARWATER, FL 33757-8744
United States

Phone: 727-532-0002 | Fax: 727-266-4943
View Map External Link
Primary Practice Address 116 1ST ST N
ST PETERSBURG, FL 33701-3305
United States

Phone: 727-895-5210 | Fax: 727-821-4297
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
MEDICAID FL 012130600
Primary Taxonomy Selected Taxonomy State License Number
Yes 207Q00000X - Family Medicine FL OS11961