Healthcare Provider Details

I. General information

NPI: 1043079072
Provider Name (Legal Business Name): KRISTEN IDOWU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2024
Last Update Date: 03/13/2024
Certification Date: 03/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12236 TAVARES RIDGE LN
TAVARES FL
32778-4460
US

IV. Provider business mailing address

12236 TAVARES RIDGE LN
TAVARES FL
32778-4460
US

V. Phone/Fax

Practice location:
  • Phone: 352-636-2821
  • Fax:
Mailing address:
  • Phone: 352-636-2821
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: