Healthcare Provider Details

I. General information

NPI: 1568022523
Provider Name (Legal Business Name): KRYSTAL K CASANOVA ENCARNACION APRN.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRYSTAL K GORDON APRN.

II. Dates (important events)

Enumeration Date: 06/20/2019
Last Update Date: 02/11/2025
Certification Date: 02/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16230 SUMMERLIN RD STE 215
FORT MYERS FL
33908-5769
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-7474
  • Fax: 239-343-4190
Mailing address:
  • Phone: 239-424-1500
  • Fax: 239-424-1423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License NumberAPRN11002846
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: