Healthcare Provider Details

I. General information

NPI: 1790995025
Provider Name (Legal Business Name): MISS GLORIA HEPBURN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 07/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8616 FISH LAKE RD 8616 FISH LAKE RD
TAMPA FL
33619-4929
US

IV. Provider business mailing address

8616 FISH LAKE RD NONE
TAMPA FL
33619-4929
US

V. Phone/Fax

Practice location:
  • Phone: 813-758-5393
  • Fax:
Mailing address:
  • Phone: 813-758-5393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: