Healthcare Provider Details

I. General information

NPI: 1649986167
Provider Name (Legal Business Name): SULEMA GARCIA REQUEJO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2023
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6806 LONGPOINTE WAY
TAMPA FL
33615-5821
US

IV. Provider business mailing address

6806 LONGPOINTE WAY
TAMPA FL
33615-5821
US

V. Phone/Fax

Practice location:
  • Phone: 813-475-2410
  • Fax:
Mailing address:
  • Phone: 813-475-2410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11023348
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: