=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144756172
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOANNA MULDER NP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2017
-----------------------------------------------------
Last Update Date | 05/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2553 MASON OAKS DR
-----------------------------------------------------
City | VALRICO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33596-6498
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-940-6046
-----------------------------------------------------
Fax | 866-451-4607
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2553 MASON OAKS DR
-----------------------------------------------------
City | VALRICO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33596-6498
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-940-6046
-----------------------------------------------------
Fax | 866-451-4607
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHANIE E ELLISON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 813-376-0742
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------