Healthcare Provider Details

I. General information

NPI: 1215816418
Provider Name (Legal Business Name): MAXINE KAREN DZOTEFE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MAXINE KAREN MCLEAN

II. Dates (important events)

Enumeration Date: 09/01/2025
Last Update Date: 09/01/2025
Certification Date: 08/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5428 IMAGINATION DR
FORT PIERCE FL
34947-5484
US

IV. Provider business mailing address

5428 IMAGINATION DR
FORT PIERCE FL
34947-5484
US

V. Phone/Fax

Practice location:
  • Phone: 850-896-2133
  • Fax:
Mailing address:
  • Phone: 850-896-2133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number444638
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: