Healthcare Provider Details

I. General information

NPI: 1578300190
Provider Name (Legal Business Name): TRISHA PHOUPARDIT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 07/11/2024
Certification Date: 07/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 W STATE ROAD 434
LONGWOOD FL
32750-5119
US

IV. Provider business mailing address

1 LOUIE B NUNN DR
NEWPORT KY
41099-9992
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11033913
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: