Healthcare Provider Details

I. General information

NPI: 1346171444
Provider Name (Legal Business Name): THE FOREVER YOUNG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19727 THE PLACE BLVD
ESTERO FL
33928
US

IV. Provider business mailing address

19727 THE PLACE BLVD
ESTERO FL
33928
US

V. Phone/Fax

Practice location:
  • Phone: 239-220-8829
  • Fax:
Mailing address:
  • Phone: 239-220-8829
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: LORI K AXFORD
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 425-971-0990