Healthcare Provider Details

I. General information

NPI: 1093448102
Provider Name (Legal Business Name): INCHARGECLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2022
Last Update Date: 02/27/2025
Certification Date: 02/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12250 BLUE PACIFIC DR
RIVERVIEW FL
33579-1803
US

IV. Provider business mailing address

12250 BLUE PACIFIC DR
RIVERVIEW FL
33579-1803
US

V. Phone/Fax

Practice location:
  • Phone: 813-955-9734
  • Fax: 813-366-8789
Mailing address:
  • Phone:
  • Fax: 813-336-8789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JILL MARSHALL-ALLEN
Title or Position: MMGR
Credential: APRN CWS FACCWS
Phone: 813-530-9666