=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871224550
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE MAIOLO FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2022
-----------------------------------------------------
Last Update Date | 06/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6798 CROSSWINDS DR N STE E102
-----------------------------------------------------
City | SAINT PETERSBURG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33710-5479
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-999-9747
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5510 N HIMES AVE APT 1711
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33614-5776
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 585-210-0852
-----------------------------------------------------
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 | APRN11019036
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------