=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487587556
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRUSSIAN BLUE HEALTH, WELLNESS AND FITNESS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2026
-----------------------------------------------------
Last Update Date | 06/08/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6101 W ATLANTIC BLVD STE 101
-----------------------------------------------------
City | MARGATE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33063-5157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-587-0915
-----------------------------------------------------
Fax | 786-761-9231
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6101 W ATLANTIC BLVD STE 101
-----------------------------------------------------
City | MARGATE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33063-5157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-587-0915
-----------------------------------------------------
Fax | 786-761-9231
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | CARLA PETION
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 786-587-0915
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------