Healthcare Provider Details

I. General information

NPI: 1134886781
Provider Name (Legal Business Name): MRS. THELMA HAILE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2021
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9833 E COLONIAL DR
ORLANDO FL
32817-4206
US

IV. Provider business mailing address

9833 E COLONIAL DR
ORLANDO FL
32817-4206
US

V. Phone/Fax

Practice location:
  • Phone: 407-876-6699
  • Fax:
Mailing address:
  • Phone: 407-876-6699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number11016179
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: