Healthcare Provider Details

I. General information

NPI: 1417817875
Provider Name (Legal Business Name): PHOENIX FULLENWIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2025
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 FORTANINI CIR
OCOEE FL
34761-5077
US

IV. Provider business mailing address

630 FORTANINI CIR
OCOEE FL
34761-5077
US

V. Phone/Fax

Practice location:
  • Phone: 321-464-9672
  • Fax:
Mailing address:
  • Phone: 321-464-9672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: