Healthcare Provider Details

I. General information

NPI: 1508681040
Provider Name (Legal Business Name): SAMERAWIT TADELE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2024
Last Update Date: 11/19/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4151 HUNTERS PARK LN STE 108
ORLANDO FL
32837-3617
US

IV. Provider business mailing address

1438 SUN MEADOW DR
ORLANDO FL
32824-5112
US

V. Phone/Fax

Practice location:
  • Phone: 407-898-2767
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number11035152
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: