=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770239808
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ZEN ORCHID MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2022
-----------------------------------------------------
Last Update Date | 02/28/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5800 49TH ST N # S-103
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33709-2146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-471-6372
-----------------------------------------------------
Fax | 727-471-4956
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5800 49TH ST N # S-103
-----------------------------------------------------
City | ST PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33709-2146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-471-6372
-----------------------------------------------------
Fax | 727-471-4956
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER/EMPLOYEE
-----------------------------------------------------
Name | PATRICIA ANNE THOMAS-BOLDEN
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 727-471-6372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------