Healthcare Provider Details

I. General information

NPI: 1578309902
Provider Name (Legal Business Name): EMPOWER LIFESTYLE MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/04/2024
Last Update Date: 07/04/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5208 SW 91ST DR STE E
GAINESVILLE FL
32608-9117
US

IV. Provider business mailing address

9200 NW 39TH AVE STE 130 PO BOX 3239
GAINESVILLE FL
32606-7366
US

V. Phone/Fax

Practice location:
  • Phone: 352-200-2465
  • Fax:
Mailing address:
  • Phone: 352-682-5640
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: VOLHA IHNATSENKA
Title or Position: MD
Credential:
Phone: 352-682-5306