Healthcare Provider Details

I. General information

NPI: 1407139371
Provider Name (Legal Business Name): SASHI A ZICKEFOOSE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 06/08/2025
Certification Date: 06/08/2025
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

3761 S. NOVA RD STE P #1050
PORT ORANGE FL
32129-4284
US

V. Phone/Fax

Practice location:
  • Phone: 386-295-6601
  • Fax:
Mailing address:
  • Phone: 386-886-2492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN116155
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP4449
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11014840
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: