Healthcare Provider Details

I. General information

NPI: 1164072773
Provider Name (Legal Business Name): DARLA ANN LAGORSE NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DARLA ANN EIKELBOOM NNP

II. Dates (important events)

Enumeration Date: 09/16/2019
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

V. Phone/Fax

Practice location:
  • Phone: 407-303-2528
  • Fax:
Mailing address:
  • Phone: 407-303-2528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704224783
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number4704224783
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberAPRN11032193
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: