=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417631763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA DOLORES KRITZMAN CNA231468/HHA/BLS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2023
-----------------------------------------------------
Last Update Date | 06/14/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1302 PARK AVE
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778-2352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-702-5024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1302 PARK AVE
-----------------------------------------------------
City | TAVARES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32778-2352
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-702-5024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747A0650X
-----------------------------------------------------
Taxonomy Name | Attendant Care Provider
-----------------------------------------------------
License Number | CNA231468
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------