=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922749522
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | READY 4 THE CHANGE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2022
-----------------------------------------------------
Last Update Date | 04/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13630 SUMMER RAIN DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32828-7447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-945-3502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13630 SUMMER RAIN DR
-----------------------------------------------------
City | ORLANDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32828-7447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-945-3502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SAMANTHA AZAM
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 407-923-0999
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------