Healthcare Provider Details

I. General information

NPI: 1518425131
Provider Name (Legal Business Name): SHINUMOL SABU APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/04/2019
Last Update Date: 02/21/2021
Certification Date: 02/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19015 US HIGHWAY 441
MOUNT DORA FL
32757-6708
US

IV. Provider business mailing address

19015 US HIGHWAY 441
MOUNT DORA FL
32757-6708
US

V. Phone/Fax

Practice location:
  • Phone: 352-383-3484
  • Fax: 352-735-0517
Mailing address:
  • Phone: 352-383-3484
  • Fax: 352-735-0517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11001435
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: