Healthcare Provider Details

I. General information

NPI: 1750132940
Provider Name (Legal Business Name): TEQUILA MONOA HILL NURSE AIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2024
Last Update Date: 03/28/2024
Certification Date: 03/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1045 US HIGHWAY 17 S
BARTOW FL
33830-6027
US

IV. Provider business mailing address

1940 SADDLEWOOD CT
BARTOW FL
33830-2916
US

V. Phone/Fax

Practice location:
  • Phone: 717-331-7371
  • Fax:
Mailing address:
  • Phone: 717-331-7371
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number20012035
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: