Healthcare Provider Details

I. General information

NPI: 1477058774
Provider Name (Legal Business Name): SANDRA HECTOR PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2018
Last Update Date: 03/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10150 HIGHLAND MANOR DR
TAMPA FL
33610-9713
US

IV. Provider business mailing address

10280 POST HARVEST DR
RIVERVIEW FL
33578-3656
US

V. Phone/Fax

Practice location:
  • Phone: 813-314-2469
  • Fax:
Mailing address:
  • Phone: 813-500-1065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: