Healthcare Provider Details

I. General information

NPI: 1740253780
Provider Name (Legal Business Name): CAROLYN L DELOACHE MSN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 E MAIN ST
LAKE BUTLER FL
32054-1353
US

IV. Provider business mailing address

130 SW 123RD ST
NEWBERRY FL
32669-3005
US

V. Phone/Fax

Practice location:
  • Phone: 386-496-2323
  • Fax: 352-495-3401
Mailing address:
  • Phone: 352-332-4541
  • Fax: 352-495-3401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1699072
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: