=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063205425
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SANARA CLINICAL SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2025
-----------------------------------------------------
Last Update Date | 05/27/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 104 W MILLER ST UNIT 435
-----------------------------------------------------
City | FRUITLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34731-7018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-399-8124
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 104 W MILLER ST UNIT 435
-----------------------------------------------------
City | FRUITLAND PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34731-7018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-399-8124
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE OWNER
-----------------------------------------------------
Name | JESSICA MOSCOSO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 352-399-8124
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------