Healthcare Provider Details

I. General information

NPI: 1811327513
Provider Name (Legal Business Name): MARY KRISTIN SURPRENANT LM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 06/10/2020
Certification Date: 06/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 JAMELA DR
OCOEE FL
34761-1905
US

IV. Provider business mailing address

903 JAMELA DR
OCOEE FL
34761-1905
US

V. Phone/Fax

Practice location:
  • Phone: 407-466-5982
  • Fax: 407-359-5028
Mailing address:
  • Phone: 407-644-5567
  • Fax: 407-644-4975

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberMW287
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: