Healthcare Provider Details

I. General information

NPI: 1992499685
Provider Name (Legal Business Name): ISLAND DERMATOLOGY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 07/01/2024
Certification Date: 07/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6470 US HIGHWAY 1
ROCKLEDGE FL
32955-5747
US

IV. Provider business mailing address

6470 US1
ROCKLEDGE FL
32955-5226
US

V. Phone/Fax

Practice location:
  • Phone: 321-693-6330
  • Fax:
Mailing address:
  • Phone: 321-693-6330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN VERPAELE
Title or Position: APRN
Credential: APRN
Phone: 321-693-6330