MEDICARE: FELICIA LAVERNE BRISTOL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171W00000X	Contractor	L21000139942	FL

General Provider Information

NPI Number	:	1336001866
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FELICIA LAVERNE BRISTOL

Provider Business Mailing Address
First Line	:	2549 15TH AVE S
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33712-2150
Country	:	US
Telephone Number	:	727-686-1689
Fax Number	:

Provider Business Practice Location Address
First Line	:	2549 15TH AVE S
Second Line	:
City	:	SAINT PETERSBURG
State	:	FL
Zip	:	33712-2150
Country	:	US
Telephone Number	:	727-686-1689
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/02/2025
Last Update Date	:	12/02/2025

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Directions to “ FELICIA LAVERNE BRISTOL ” Practice Location

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