=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639922099
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAYKEL MORENO ABREU
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2024
-----------------------------------------------------
Last Update Date | 05/02/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 675 S KINGS AVE
-----------------------------------------------------
City | BRANDON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33511-6048
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 813-588-5123
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4540 PENKERT PL
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33811-2470
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 567-377-1288
-----------------------------------------------------
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 | F04240216
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------