Healthcare Provider Details

I. General information

NPI: 1902138217
Provider Name (Legal Business Name): REKHA NIDADAVOLU PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: REKHA PINJALA PHARM-D

II. Dates (important events)

Enumeration Date: 02/11/2010
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4745 OLD CANOE CREEK RD
SAINT CLOUD FL
34769-1400
US

IV. Provider business mailing address

4745 OLD CANOE CREEK RD
SAINT CLOUD FL
34769-1400
US

V. Phone/Fax

Practice location:
  • Phone: 305-905-9316
  • Fax:
Mailing address:
  • Phone: 305-905-9316
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License NumberPS44664
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24667
License Number StateMA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9111839
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: