Healthcare Provider Details

I. General information

NPI: 1164298352
Provider Name (Legal Business Name): BREANNA SHANTEL ZURITA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2023
Last Update Date: 11/28/2023
Certification Date: 11/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 LAKE ELLENOR DR STE 261
ORLANDO FL
32809-4638
US

IV. Provider business mailing address

4401 W KNOX ST
TAMPA FL
33614-3612
US

V. Phone/Fax

Practice location:
  • Phone: 407-968-7807
  • Fax:
Mailing address:
  • Phone: 813-999-6051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number6583
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: