Healthcare Provider Details

I. General information

NPI: 1831802305
Provider Name (Legal Business Name): MYRNA DEL CARMEN COLOM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2022
Last Update Date: 12/29/2022
Certification Date: 12/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 BIG TREE RD
SOUTH DAYTONA FL
32119-2922
US

IV. Provider business mailing address

322 BIG TREE RD
SOUTH DAYTONA FL
32119-2922
US

V. Phone/Fax

Practice location:
  • Phone: 386-310-8745
  • Fax:
Mailing address:
  • Phone: 386-310-8745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11023390
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: