Healthcare Provider Details

I. General information

NPI: 1205409372
Provider Name (Legal Business Name): ANGELA DENNIS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 05/18/2023
Certification Date: 05/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1314 OAK ST
MELBOURNE FL
32901-3111
US

IV. Provider business mailing address

1314 OAK ST
MELBOURNE FL
32901-3111
US

V. Phone/Fax

Practice location:
  • Phone: 321-727-7992
  • Fax: 321-727-7664
Mailing address:
  • Phone: 321-727-7992
  • Fax: 321-727-7664

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11014205
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: