Healthcare Provider Details

I. General information

NPI: 1265891816
Provider Name (Legal Business Name): DIANE GELLERMANN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4645 CLYDE MORRIS BLVD STE 408
PORT ORANGE FL
32129-3005
US

IV. Provider business mailing address

4645 CLYDE MORRIS BLVD STE 408
PORT ORANGE FL
32129-3005
US

V. Phone/Fax

Practice location:
  • Phone: 386-295-6601
  • Fax: 386-492-1174
Mailing address:
  • Phone: 386-690-5343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9230757
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: