Healthcare Provider Details

I. General information

NPI: 1437781986
Provider Name (Legal Business Name): CHARISSE FARRELL APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5401 S CONGRESS AVE STE 204
ATLANTIS FL
33462-6637
US

IV. Provider business mailing address

5952 BUTTONBUSH DR
WESTLAKE FL
33470-6500
US

V. Phone/Fax

Practice location:
  • Phone: 561-967-4118
  • Fax:
Mailing address:
  • Phone: 561-506-8335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11006132
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: