Healthcare Provider Details

I. General information

NPI: 1639573157
Provider Name (Legal Business Name): SIMON LAINE ARNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2014
Last Update Date: 08/05/2022
Certification Date: 08/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5010 HOLLYWOOD BLVD STE 100B
HOLLYWOOD FL
33021-6557
US

IV. Provider business mailing address

5010 HOLLYWOOD BLVD STE 100B
HOLLYWOOD FL
33021-6557
US

V. Phone/Fax

Practice location:
  • Phone: 954-967-0028
  • Fax:
Mailing address:
  • Phone: 954-967-0028
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9113024
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP9313024
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: