=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669180881
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUNRISE FAMILY PRACTICE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2022
-----------------------------------------------------
Last Update Date | 11/07/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 NE 19TH DR
-----------------------------------------------------
City | OKEECHOBEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34972-1933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-467-8398
-----------------------------------------------------
Fax | 863-467-9850
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 NE 19TH DR
-----------------------------------------------------
City | OKEECHOBEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34972-1933
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-467-8398
-----------------------------------------------------
Fax | 863-467-9850
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTIONER
-----------------------------------------------------
Name | SUNITA DHILLON
-----------------------------------------------------
Credential | ARNP
-----------------------------------------------------
Telephone | 863-467-8398
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------