Healthcare Provider Details

I. General information

NPI: 1942454491
Provider Name (Legal Business Name): BAMBI WEINER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

121 PINE DR
INTERLACHEN FL
32148-5745
US

IV. Provider business mailing address

121 PINE DR
INTERLACHEN FL
32148-5745
US

V. Phone/Fax

Practice location:
  • Phone: 386-684-4523
  • Fax:
Mailing address:
  • Phone: 386-684-4523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License NumberW560-077-58-878-0
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: