Healthcare Provider Details

I. General information

NPI: 1215392154
Provider Name (Legal Business Name): TERESITA RYAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESITA HENAO ARNP

II. Dates (important events)

Enumeration Date: 12/18/2015
Last Update Date: 06/09/2023
Certification Date: 06/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 GRAPE AVE
SAINT CLOUD FL
34769-3965
US

IV. Provider business mailing address

1877 FORTUNE RD
KISSIMMEE FL
34744-4428
US

V. Phone/Fax

Practice location:
  • Phone: 407-943-8600
  • Fax: 833-464-3650
Mailing address:
  • Phone: 407-943-8600
  • Fax: 407-932-5150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9298416
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9298416
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: