Healthcare Provider Details

I. General information

NPI: 1356731715
Provider Name (Legal Business Name): DOROTHY DAWN IBASCO APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

450 E MERRITT ISLAND CSWY STE 200
MERRITT ISLAND FL
32952-3503
US

IV. Provider business mailing address

PO BOX 947387
ATLANTA GA
30394-7387
US

V. Phone/Fax

Practice location:
  • Phone: 321-735-6220
  • Fax: 321-507-4638
Mailing address:
  • Phone: 407-447-7120
  • Fax: 407-770-0661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP 9352814
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License NumberAPRN9352814
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: