Healthcare Provider Details

I. General information

NPI: 1477158384
Provider Name (Legal Business Name): VENETIA ETKINS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 12/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 W COLONIAL DR
OCOEE FL
34761-3400
US

IV. Provider business mailing address

7602 TEAKWOOD PL
MOUNT DORA FL
32757-7200
US

V. Phone/Fax

Practice location:
  • Phone: 407-296-1000
  • Fax:
Mailing address:
  • Phone: 407-719-3245
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF12190487
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: