Healthcare Provider Details

I. General information

NPI: 1619604246
Provider Name (Legal Business Name): RENIDE SHELCY MILFORT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2022
Last Update Date: 08/28/2022
Certification Date: 08/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W STATE ROAD 434
LONGWOOD FL
32750-5119
US

IV. Provider business mailing address

1687 BREWTON CIR
DELTONA FL
32738-5346
US

V. Phone/Fax

Practice location:
  • Phone: 407-767-1200
  • Fax:
Mailing address:
  • Phone: 561-305-9196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11021195
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: