=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578011987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEGS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/14/2016
-----------------------------------------------------
Last Update Date | 04/03/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1964 HOWELL BRANCH RD SUITE 100
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32792-1042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-276-7326
-----------------------------------------------------
Fax | 407-264-8261
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1964 HOWELL BRANCH RD SUITE 100
-----------------------------------------------------
City | WINTER PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32792-1042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-276-7326
-----------------------------------------------------
Fax | 407-264-8261
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | REBECCA KAY BRILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-276-7326
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | ARNP9163789
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------