Healthcare Provider Details

I. General information

NPI: 1639986201
Provider Name (Legal Business Name): SHALIEZAR ANDERSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2024
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14203 CLARENDON DR
TAMPA FL
33624-2626
US

IV. Provider business mailing address

14203 CLARENDON DR
TAMPA FL
33624-2626
US

V. Phone/Fax

Practice location:
  • Phone: 813-850-6767
  • Fax:
Mailing address:
  • Phone: 813-850-6767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11036243
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: