Healthcare Provider Details

I. General information

NPI: 1710712328
Provider Name (Legal Business Name): EDMUND EMMANUAL LATIF III APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2024
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9332 STATE ROAD 54 STE 405
TRINITY FL
34655-1810
US

IV. Provider business mailing address

2722 HEATHGATE WAY
LAND O LAKES FL
34638-7255
US

V. Phone/Fax

Practice location:
  • Phone: 727-375-8264
  • Fax:
Mailing address:
  • Phone: 813-847-3315
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9381707
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN11036328
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: