Healthcare Provider Details

I. General information

NPI: 1538784780
Provider Name (Legal Business Name): KRISTEN N MOELLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2020
Last Update Date: 11/01/2022
Certification Date: 11/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7814 N DALE MABRY HWY
TAMPA FL
33614-3220
US

IV. Provider business mailing address

8309 BELLA GROVE CIR UNIT 203
SARASOTA FL
34243-2114
US

V. Phone/Fax

Practice location:
  • Phone: 813-397-5300
  • Fax: 813-405-3938
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: