Healthcare Provider Details

I. General information

NPI: 1396652301
Provider Name (Legal Business Name): TIMOTHY EUSTACE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2971 PARK POND WAY
KISSIMMEE FL
34741-7661
US

IV. Provider business mailing address

2971 PARK POND WAY
KISSIMMEE FL
34741-7661
US

V. Phone/Fax

Practice location:
  • Phone: 407-775-2121
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11050305
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: