Healthcare Provider Details

I. General information

NPI: 1497619381
Provider Name (Legal Business Name): TEQUILA FLETCHER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11970 N FLORIDA AVE
TAMPA FL
33612-5222
US

IV. Provider business mailing address

11970 N FLORIDA AVE
TAMPA FL
33612-5222
US

V. Phone/Fax

Practice location:
  • Phone: 813-390-8497
  • Fax:
Mailing address:
  • Phone: 813-390-8497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberCE10007425
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: