Healthcare Provider Details

I. General information

NPI: 1740067818
Provider Name (Legal Business Name): MARY ELISABETH MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2023
Last Update Date: 09/12/2023
Certification Date: 09/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12729 TANNENCREST DR
RIVERVIEW FL
33579-9415
US

IV. Provider business mailing address

12729 TANNENCREST DR
RIVERVIEW FL
33579-9415
US

V. Phone/Fax

Practice location:
  • Phone: 727-645-1955
  • Fax:
Mailing address:
  • Phone: 727-645-1955
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License NumberM200-585-87-866-0
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: