Healthcare Provider Details

I. General information

NPI: 1962019836
Provider Name (Legal Business Name): TIA DANIELLE GLOSTER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8925 COLONIAL CENTER DR STE 1000
FORT MYERS FL
33905-7813
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-9560
  • Fax: 239-343-9624
Mailing address:
  • Phone: 239-343-9560
  • Fax: 239-343-9624

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN11006074
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: