Healthcare Provider Details

I. General information

NPI: 1902393002
Provider Name (Legal Business Name): MICHELLE DOUBLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2018
Last Update Date: 05/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4850 SE 110TH ST
BELLEVIEW FL
34420
US

IV. Provider business mailing address

4850 SE 110TH ST
BELLEVIEW FL
34420-3118
US

V. Phone/Fax

Practice location:
  • Phone: 352-233-2360
  • Fax: 352-690-2171
Mailing address:
  • Phone: 352-690-2171
  • Fax: 352-690-6954

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberARNP9362866
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: