Healthcare Provider Details

I. General information

NPI: 1821493891
Provider Name (Legal Business Name): VIDYA JAIMUNGAL ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2014
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2237 LITHIA CENTER LN
VALRICO FL
33596-5676
US

IV. Provider business mailing address

2675 WINKLER AVE FL 2
FORT MYERS FL
33901-9342
US

V. Phone/Fax

Practice location:
  • Phone: 813-662-0123
  • Fax: 813-662-9422
Mailing address:
  • Phone: 877-856-3774
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9167965
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: