Healthcare Provider Details

I. General information

NPI: 1851908677
Provider Name (Legal Business Name): CAROLYN J MACIAS MSN APRN FNP BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11322 SE 55TH AVENUE RD UNIT 901
BELLEVIEW FL
34420-3749
US

IV. Provider business mailing address

11322 SE 55TH AVENUE RD UNIT 901
BELLEVIEW FL
34420-3749
US

V. Phone/Fax

Practice location:
  • Phone: 352-653-8248
  • Fax:
Mailing address:
  • Phone: 352-653-8248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11009364
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: