Healthcare Provider Details

I. General information

NPI: 1710310768
Provider Name (Legal Business Name): TINA N THEOBALD ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2013
Last Update Date: 11/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3302 W BAKER ST
PLANT CITY FL
33563-2851
US

IV. Provider business mailing address

3302 W BAKER ST
PLANT CITY FL
33563-2851
US

V. Phone/Fax

Practice location:
  • Phone: 813-752-1336
  • Fax: 813-754-6914
Mailing address:
  • Phone: 813-752-1336
  • Fax: 813-754-6914

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP9268946
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: