Healthcare Provider Details

I. General information

NPI: 1487450888
Provider Name (Legal Business Name): SAINT TERESA OF AVILA HEALTHCARE PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2025
Last Update Date: 12/19/2025
Certification Date: 12/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1766 20TH AVE STE 2
VERO BEACH FL
32960-3632
US

IV. Provider business mailing address

1766 20TH AVE STE 2
VERO BEACH FL
32960-3632
US

V. Phone/Fax

Practice location:
  • Phone: 772-539-0214
  • Fax: 772-298-4170
Mailing address:
  • Phone: 772-539-0214
  • Fax: 772-298-4170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MISS DANIELA ANDREINA IBARRA
Title or Position: AUTHORIZED OFFICIAL
Credential: NURSE PRACTITIONER
Phone: 772-539-0214