Healthcare Provider Details

I. General information

NPI: 1518577006
Provider Name (Legal Business Name): MAYBELLINE MALOMA HANSON A-GNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2020
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 N ORANGE BLOSSOM TRL
KISSIMMEE FL
34744-2316
US

IV. Provider business mailing address

1453 CLEAR BROOK PL
SAINT CLOUD FL
34772-6537
US

V. Phone/Fax

Practice location:
  • Phone: 407-846-4343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9251665
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11001250
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11001250
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: