Healthcare Provider Details

I. General information

NPI: 1679971196
Provider Name (Legal Business Name): IVELISSE GARCIA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2014
Last Update Date: 05/20/2021
Certification Date: 05/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 S MOON AVE
BRANDON FL
33511-5711
US

IV. Provider business mailing address

270 S MOON AVE
BRANDON FL
33511-5711
US

V. Phone/Fax

Practice location:
  • Phone: 813-571-9988
  • Fax: 813-571-9922
Mailing address:
  • Phone: 813-571-9988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF1114285
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: