Healthcare Provider Details

I. General information

NPI: 1659708485
Provider Name (Legal Business Name): EBONY PATRICE OLTON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2013
Last Update Date: 04/13/2022
Certification Date: 04/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11138 GOLDENROD FERN DR
RIVERVIEW FL
33569-2230
US

IV. Provider business mailing address

11138 GOLDENROD FERN DR
RIVERVIEW FL
33569-2230
US

V. Phone/Fax

Practice location:
  • Phone: 813-312-4413
  • Fax:
Mailing address:
  • Phone: 813-312-4413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN 9222592
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberARNP 9222592
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberARNP9222592
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: