=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730791567
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SANDRA R HORACE MSN, AG-ACNP, APRN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2020
-----------------------------------------------------
Last Update Date | 08/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8064 W FANDANGO CT
-----------------------------------------------------
City | CRYSTAL RIVER
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 34428-5839
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-228-7362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 348 SERVIA DR
-----------------------------------------------------
City | ST JOHNS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32259-2233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 352-228-7362
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | APRN11008371
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------