Healthcare Provider Details

I. General information

NPI: 1194701862
Provider Name (Legal Business Name): MOS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

256 SW WASHINGTON AVE
MADISON FL
32340
US

IV. Provider business mailing address

PO BOX 902
MADISON FL
32341
US

V. Phone/Fax

Practice location:
  • Phone: 850-973-4590
  • Fax: 850-973-4929
Mailing address:
  • Phone: 850-973-4590
  • Fax: 850-973-4929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1396122
License Number StateFL

VIII. Authorized Official

Name: MS. TAMMY WILLIAMS
Title or Position: OWNER
Credential: ARNP
Phone: 850-973-4590