=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376268573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEACE OF MIND PSYCHIATRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2022
-----------------------------------------------------
Last Update Date | 11/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1931 ORTEGA ST
-----------------------------------------------------
City | NAVARRE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32566-4111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-684-1410
-----------------------------------------------------
Fax | 833-989-0937
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9670 MEADOW WOOD LN
-----------------------------------------------------
City | NAVARRE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32566-2876
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/NURSE PRACTITIONER
-----------------------------------------------------
Name | MRS. ANGELA SANDERS
-----------------------------------------------------
Credential | DNP, APRN
-----------------------------------------------------
Telephone | 850-684-1410
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------