Healthcare Provider Details

I. General information

NPI: 1700529369
Provider Name (Legal Business Name): MIS PROVIDER NETWORK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2022
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 FITZGERALD RD STE 1
LAKELAND FL
33813-2633
US

IV. Provider business mailing address

170 FITZGERALD RD STE 1
LAKELAND FL
33813-2633
US

V. Phone/Fax

Practice location:
  • Phone: 813-687-5858
  • Fax:
Mailing address:
  • Phone: 813-687-5858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WENDY L BRADSHAW
Title or Position: OWNER
Credential: MD
Phone: 813-687-5858