Healthcare Provider Details

I. General information

NPI: 1083176820
Provider Name (Legal Business Name): DENIELLE WASCHEK APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2019
Last Update Date: 03/08/2022
Certification Date: 03/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4367 NW AMERICAN LN
LAKE CITY FL
32055-4828
US

IV. Provider business mailing address

4367 NW AMERICAN LN
LAKE CITY FL
32055-4828
US

V. Phone/Fax

Practice location:
  • Phone: 386-758-6094
  • Fax: 386-758-6995
Mailing address:
  • Phone: 386-758-6094
  • Fax: 386-758-6995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11001921
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: