Healthcare Provider Details

I. General information

NPI: 1336819788
Provider Name (Legal Business Name): P31 LIFE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2021
Last Update Date: 09/23/2021
Certification Date: 09/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 4TH ST N STE 300
SAINT PETERSBURG FL
33702-4399
US

IV. Provider business mailing address

7901 4TH ST N STE 300
SAINT PETERSBURG FL
33702-4399
US

V. Phone/Fax

Practice location:
  • Phone: 305-924-5397
  • Fax:
Mailing address:
  • Phone: 305-924-5397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DIANNE SMITH
Title or Position: OWNER
Credential: CRNP
Phone: 863-455-7300