Healthcare Provider Details

I. General information

NPI: 1780121277
Provider Name (Legal Business Name): NURSE PRACTITIONER GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2017
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12380 NW 9TH ST
PLANTATION FL
33325-1305
US

IV. Provider business mailing address

12380 NW 9TH ST
PLANTATION FL
33325-1305
US

V. Phone/Fax

Practice location:
  • Phone: 256-508-9034
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberARNP9224482
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License NumberR185090
License Number StateMD

VIII. Authorized Official

Name: STACEY SANTIAGO
Title or Position: OWNER
Credential:
Phone: 256-508-9034