Healthcare Provider Details

I. General information

NPI: 1952325763
Provider Name (Legal Business Name): SUSAN W LLARENA P.A.-C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1340 S 18TH ST #204
FERNANDINA BEACH FL
32034-4799
US

IV. Provider business mailing address

2675 WINKLER AVE FL 2
FORT MYERS FL
33901-9342
US

V. Phone/Fax

Practice location:
  • Phone: 904-261-0643
  • Fax: 904-277-4082
Mailing address:
  • Phone: 877-856-3774
  • Fax: 239-599-2612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 2061
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: