MEDICARE: MR. FERNANDO M ULLOA APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	574074-1	NY
2	163W00000X	Registered Nurse	RN9623430	FL
3	363LA2200X	Adult Health Nurse Practitioner	APRN11025366	FL

General Provider Information

NPI Number	:	1043459563
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FERNANDO M ULLOA APRN

Provider Business Mailing Address
First Line	:	PO BOX 350137
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32135-0137
Country	:	US
Telephone Number	:	718-721-1674
Fax Number	:

Provider Business Practice Location Address
First Line	:	61 MEMORIAL MEDICAL PKWY STE 3803
Second Line	:
City	:	PALM COAST
State	:	FL
Zip	:	32164-5982
Country	:	US
Telephone Number	:	718-721-1674
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2009
Last Update Date	:	06/12/2025

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