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General NPI Number Information
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NPI Number | 1700460383
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Entity Type | Organization
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Legal Business Name | ICONIC HEALTH LLC
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Dates
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Enumeration Date | 05/10/2021
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Last Update Date | 05/19/2021
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Provider Practice Location Address
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Address Line | 1898 W HILLSBORO BLVD STE H
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City | DEERFIELD BEACH
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State | FL
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Zip | 33442-1434
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Country | US
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Telephone | 954-571-9392
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Fax | 954-289-4888
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Provider Business Mailing Address
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Address Line | 1898 W HILLSBORO BLVD STE H
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City | DEERFIELD BEACH
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State | FL
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Zip | 33442-1434
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Country | US
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Telephone | 954-571-9392
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Fax | 954-289-4888
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Authorized Official
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Title or Position | CEO, LEAD PRACTITIONER
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Name | SARAH RAVELLI
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Credential | ARNP
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Telephone | 330-277-1131
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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