=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538651112
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGACY ADVANCED HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2018
-----------------------------------------------------
Last Update Date | 12/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1515 N UNIVERSITY DR STE 120
-----------------------------------------------------
City | CORAL SPRINGS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33071-6084
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-999-4881
-----------------------------------------------------
Fax | 772-303-3476
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 15084 WILDWOOD CIR
-----------------------------------------------------
City | WESTLAKE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33470-5435
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 772-333-7070
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | AGNP
-----------------------------------------------------
Name | PAMELA MANNING
-----------------------------------------------------
Credential | NP
-----------------------------------------------------
Telephone | 954-999-4881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------