Healthcare Provider Details

I. General information

NPI: 1831683861
Provider Name (Legal Business Name): MULBERRYS MOBILE PROVIDER SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 02/08/2021
Certification Date: 02/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6435 SE US HIGHWAY 301
HAWTHORNE FL
32640-7309
US

IV. Provider business mailing address

6435 SE US HIGHWAY 301
HAWTHORNE FL
32640-7309
US

V. Phone/Fax

Practice location:
  • Phone: 352-358-8070
  • Fax: 949-577-4783
Mailing address:
  • Phone: 352-358-8070
  • Fax: 949-577-4783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. MICHELL MULBERRY
Title or Position: PROVIDER, OWNER
Credential: DNP, APRN-BC
Phone: 352-358-8070