Healthcare Provider Details

I. General information

NPI: 1326676933
Provider Name (Legal Business Name): VIVIAN PAULINE HAIDERMOTA FNP, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14100 FIVAY RD STE 160
HUDSON FL
34667-7194
US

IV. Provider business mailing address

14100 FIVAY RD STE 160
HUDSON FL
34667-7194
US

V. Phone/Fax

Practice location:
  • Phone: 727-862-1080
  • Fax:
Mailing address:
  • Phone: 727-862-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11006795
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: