Healthcare Provider Details

I. General information

NPI: 1801609151
Provider Name (Legal Business Name): BRIANNA BLAKE DUSTIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2025
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3444 S CONGRESS AVE
PALM SPRINGS FL
33461-3022
US

IV. Provider business mailing address

3444 S CONGRESS AVE
PALM SPRINGS FL
33461-3022
US

V. Phone/Fax

Practice location:
  • Phone: 844-807-2567
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9120177
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: