Healthcare Provider Details

I. General information

NPI: 1245518976
Provider Name (Legal Business Name): CORRADO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1698 B WEST HIBISCUS BLVD SUITE B
MELBOURNE FL
32901-2639
US

IV. Provider business mailing address

1698 B WEST HIBISCUS BLVD SUITE B
MELBOURNE FL
32901-2639
US

V. Phone/Fax

Practice location:
  • Phone: 321-917-2042
  • Fax: 334-560-1469
Mailing address:
  • Phone: 321-917-2042
  • Fax: 334-560-1469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: CECILIA MARIE CORRADO
Title or Position: MGR
Credential: ARNP
Phone: 321-615-5560