Healthcare Provider Details

I. General information

NPI: 1457045809
Provider Name (Legal Business Name): LINDA SUE WARDLAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2023
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4003 S WEST SHORE BLVD APT 3406
TAMPA FL
33611-1035
US

IV. Provider business mailing address

4003 S WEST SHORE BLVD
TAMPA FL
33611-1046
US

V. Phone/Fax

Practice location:
  • Phone: 813-788-8160
  • Fax:
Mailing address:
  • Phone: 813-788-8160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11026757
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11026757
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: