Healthcare Provider Details

I. General information

NPI: 1174583629
Provider Name (Legal Business Name): PATRICIA P HOMON ARNP2143102
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 02/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1815 S KANNER HWY
STAURT FL
34994
US

IV. Provider business mailing address

1815 S KANNER HWY
STAURT FL
34994
US

V. Phone/Fax

Practice location:
  • Phone: 772-288-2992
  • Fax: 772-288-2999
Mailing address:
  • Phone: 772-288-2992
  • Fax: 772-288-2999

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberAPRN2143102
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier104139600
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: