MEDICARE: SAINT TERESA OF AVILA HEALTHCARE PA

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363LP2300X	Primary Care Nurse Practitioner
2	207Q00000X	Family Medicine Physician
3	261QM0850X	Adult Mental Health Clinic/Center
4	261QM1300X	Multi-Specialty Clinic/Center
5	261QM0855X	Adolescent and Children Mental Health Clinic/Center
6	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1487450888
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAINT TERESA OF AVILA HEALTHCARE PA

Provider Business Mailing Address
First Line	:	1766 20TH AVE STE 2
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-3632
Country	:	US
Telephone Number	:	772-539-0214
Fax Number	:	772-298-4170

Provider Business Practice Location Address
First Line	:	1766 20TH AVE STE 2
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-3632
Country	:	US
Telephone Number	:	772-539-0214
Fax Number	:	772-298-4170

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MISS DANIELA ANDREINA IBARRA
Credential	:	NURSE PRACTITIONER
Telephone Number	:	772-539-0214

Provider Enumeration Date	:	02/25/2025
Last Update Date	:	12/19/2025

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