Healthcare Provider Details

I. General information

NPI: 1922880111
Provider Name (Legal Business Name): KEITHLYN C ECCLES AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KEITHLYN C WHARWOOD AUSTIN

II. Dates (important events)

Enumeration Date: 10/20/2023
Last Update Date: 10/20/2023
Certification Date: 10/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4712 SW 185TH AVE # A
MIRAMAR FL
33029-6226
US

IV. Provider business mailing address

4712 SW 185TH AVE # A
MIRAMAR FL
33029-6226
US

V. Phone/Fax

Practice location:
  • Phone: 305-762-2103
  • Fax:
Mailing address:
  • Phone: 305-762-2103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number928-896
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: