=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578078580
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY MARIE WASINGER
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2017
-----------------------------------------------------
Last Update Date | 12/13/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8136 SEQUESTER LOOP
-----------------------------------------------------
City | LAND O LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34637-7667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-458-2701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8136 SEQUESTER LOOP
-----------------------------------------------------
City | LAND O LAKES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34637-7667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-458-2701
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | ARNP9199055
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------