=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972816056
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CARLA D FUENTES-BLANCO ARNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2010
-----------------------------------------------------
Last Update Date | 06/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20 E MELBOURNE AVE STE 101
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32901-5970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-312-1167
-----------------------------------------------------
Fax | 321-312-1201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 601 S HARBOUR ISLAND BLVD STE 200
-----------------------------------------------------
City | TAMPA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33602-5925
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 727-322-3439
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | ARNP9191793
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------