Healthcare Provider Details

I. General information

NPI: 1114852795
Provider Name (Legal Business Name): AMBERAL SHANTA HANSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2026
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 TIFTON ST
WINTER HAVEN FL
33880-6174
US

IV. Provider business mailing address

204 TIFTON ST
WINTER HAVEN FL
33880-6174
US

V. Phone/Fax

Practice location:
  • Phone: 863-400-9513
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN5199753
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: