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General NPI Number Information
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NPI Number | 1275963662
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Entity Type | Organization
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Legal Business Name | GENERATIONSPAN HEALTHCARE LLC
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Dates
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Enumeration Date | 11/21/2013
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Last Update Date | 11/21/2013
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Provider Practice Location Address
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Address Line | 400 CAPITAL CIR SE STE 18128
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City | TALLAHASSEE
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State | FL
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Zip | 32301-3802
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Country | US
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Telephone | 850-264-9070
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Fax |
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Provider Business Mailing Address
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Address Line | 6271 WILLIAMS RD
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City | TALLAHASSEE
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State | FL
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Zip | 32311-8526
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Country | US
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Telephone | 850-264-9070
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MS. FLORENCE PEDATIN BAMGBOSE
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Credential | PHD ARNP
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Telephone | 850-264-9070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number | 3314182
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License Number State | FL
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