Healthcare Provider Details

I. General information

NPI: 1811553480
Provider Name (Legal Business Name): MANDALY CLAUDE LOUIS-CHARLES APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2019
Last Update Date: 02/05/2020
Certification Date: 02/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12470 TELECOM DR STE 300W
TEMPLE TERRACE FL
33637-0904
US

IV. Provider business mailing address

3841 NIGHTHAWK DR
PALM HARBOR FL
34684-4132
US

V. Phone/Fax

Practice location:
  • Phone: 813-871-8183
  • Fax:
Mailing address:
  • Phone: 727-504-6986
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11002656
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: