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Provider Information for 1578994497

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: 1578994497

Calendar   Last Updated:  2014-02-27
  Certification Date: 


Name Value
NPI 1578994497
Enumeration Date 2013-12-02
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 13110 ELK MOUNTAIN DR
RIVERVIEW, FL 33579-7182
United States

Phone: 813-349-7568 | Fax: 813-349-7561
View Map External Link
Primary Practice Address 508 N MARYLAND AVE
PLANT CITY, FL 33563-3820
United States

Phone: 813-349-7600 | Fax: 813-349-7661
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 003123200
Primary Taxonomy Selected Taxonomy State License Number
Yes 363LF0000X - Nurse Practitioner Family FL ARNP9237520