Healthcare Provider Details

I. General information

NPI: 1336001866
Provider Name (Legal Business Name): FELICIA LAVERNE BRISTOL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2549 15TH AVE S
SAINT PETERSBURG FL
33712-2150
US

IV. Provider business mailing address

2549 15TH AVE S
SAINT PETERSBURG FL
33712-2150
US

V. Phone/Fax

Practice location:
  • Phone: 727-686-1689
  • Fax:
Mailing address:
  • Phone: 727-686-1689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberL21000139942
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: