=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124648639
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELEANOR THEOBALD PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2020
-----------------------------------------------------
Last Update Date | 10/24/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1010 S FEDERAL HWY STE 1010
-----------------------------------------------------
City | DELRAY BEACH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33483-5132
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-413-9511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 408 NE 6TH ST UNIT 334
-----------------------------------------------------
City | FT LAUDERDALE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33304-6407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 443-837-8805
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | PA9116006
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------