Healthcare Provider Details

I. General information

NPI: 1124787742
Provider Name (Legal Business Name): CASSANDRA NICHOLE WARNER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS CASSANDRA NICHOLE LEE

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4090 S RIDGEWOOD AVE
PORT ORANGE FL
32127-4501
US

IV. Provider business mailing address

6101 BLUE LAGOON DR STE 200
MIAMI FL
33126-3168
US

V. Phone/Fax

Practice location:
  • Phone: 386-761-0050
  • Fax: 386-761-1167
Mailing address:
  • Phone: 305-500-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11016401
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: