MEDICARE: FUNCTIONAL MEDICINE APRN LLC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1588311914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FUNCTIONAL MEDICINE APRN LLC

Provider Business Mailing Address
First Line	:	3700 GOLDEN GATE BLVD W
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34120-3043
Country	:	US
Telephone Number	:	239-601-4659
Fax Number	:

Provider Business Practice Location Address
First Line	:	7385 RADIO RD STE 104
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34104-6705
Country	:	US
Telephone Number	:	239-601-4659
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KATHY VERDES
Credential	:	APRN
Telephone Number	:	239-601-4659

Provider Enumeration Date	:	03/05/2022
Last Update Date	:	03/14/2022

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