Healthcare Provider Details

I. General information

NPI: 1851253447
Provider Name (Legal Business Name): ANTOINISE SERVIUS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3036 KUMQUAT DR
EDGEWATER FL
32141-6212
US

IV. Provider business mailing address

3036 KUMQUAT DR
EDGEWATER FL
32141-6212
US

V. Phone/Fax

Practice location:
  • Phone: 786-320-2550
  • Fax:
Mailing address:
  • Phone: 786-320-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF11250171
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: