Healthcare Provider Details

I. General information

NPI: 1316921851
Provider Name (Legal Business Name): ELLEN M. HOOKER RD CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2005
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 5TH AVE NORTH STE 302
ST PETERSBURG FL
33705-1457
US

IV. Provider business mailing address

1201 5TH AVE NORTH STE 302
ST PETERSBURG FL
33705-1457
US

V. Phone/Fax

Practice location:
  • Phone: 727-821-2388
  • Fax: 727-821-6887
Mailing address:
  • Phone: 727-821-2388
  • Fax: 727-821-6887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberND613
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: