Healthcare Provider Details

I. General information

NPI: 1376272823
Provider Name (Legal Business Name): RISA WELETCKA CLAYTON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 01/14/2025
Certification Date: 01/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 US HIGHWAY 27 SW
BRANFORD FL
32008-2767
US

IV. Provider business mailing address

23476 NW 186TH AVE
HIGH SPRINGS FL
32643-0673
US

V. Phone/Fax

Practice location:
  • Phone: 386-935-3090
  • Fax: 386-935-3198
Mailing address:
  • Phone: 386-454-0698
  • Fax: 386-454-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11019926
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: