Healthcare Provider Details

I. General information

NPI: 1306519681
Provider Name (Legal Business Name): ODALIS GARCIA PANEQUE APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2021
Last Update Date: 07/31/2021
Certification Date: 07/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4507 N ARMENIA AVE
TAMPA FL
33603-2703
US

IV. Provider business mailing address

4507 N ARMENIA AVE
TAMPA FL
33603-2703
US

V. Phone/Fax

Practice location:
  • Phone: 813-876-4100
  • Fax:
Mailing address:
  • Phone: 813-876-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11013302
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: