Healthcare Provider Details

I. General information

NPI: 1215576590
Provider Name (Legal Business Name): ETHAN ANTHONY REULET
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 07/11/2026
Certification Date: 07/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17136 SE 109TH TERRACE RD STE 4
SUMMERFIELD FL
34491-9032
US

IV. Provider business mailing address

17136 SE 109TH TERRACE RD STE 4
SUMMERFIELD FL
34491-9032
US

V. Phone/Fax

Practice location:
  • Phone: 352-320-6154
  • Fax:
Mailing address:
  • Phone: 352-320-6154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11038180
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: