Healthcare Provider Details

I. General information

NPI: 1700450632
Provider Name (Legal Business Name): ADVANCE PRACTICE/FINE FOR NO REASSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2021
Last Update Date: 05/15/2021
Certification Date: 05/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11600 NW 18TH ST
PEMBROKE PINES FL
33026-2057
US

IV. Provider business mailing address

11600 NW 18TH ST
PEMBROKE PINES FL
33026-2057
US

V. Phone/Fax

Practice location:
  • Phone: 954-834-3669
  • Fax:
Mailing address:
  • Phone: 954-834-3669
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: DR. SHIRLEY MOISE
Title or Position: DOCTOR OF NURSING PRACTICE
Credential: DNP
Phone: 954-834-3669