Healthcare Provider Details

I. General information

NPI: 1386269017
Provider Name (Legal Business Name): FAITH SELECT ZOLFAGHARI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 STATE ROAD 436 STE 1600
CASSELBERRY FL
32707-6182
US

IV. Provider business mailing address

4930 E LAKE MARY BLVD
SANFORD FL
32771-5003
US

V. Phone/Fax

Practice location:
  • Phone: 407-322-8645
  • Fax: 407-269-8986
Mailing address:
  • Phone: 407-322-8645
  • Fax: 407-269-8986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9365224
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11007314
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: