MEDICARE: HYDRATION EXPERIENCE

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	363L00000X	Nurse Practitioner

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1679167894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HYDRATION EXPERIENCE

Provider Business Mailing Address
First Line	:	1329 NW 10TH ST
Second Line	:
City	:	DANIA BEACH
State	:	FL
Zip	:	33004-2341
Country	:	US
Telephone Number	:	954-765-9521
Fax Number	:

Provider Business Practice Location Address
First Line	:	1329 NW 10TH ST
Second Line	:
City	:	DANIA BEACH
State	:	FL
Zip	:	33004-2341
Country	:	US
Telephone Number	:	954-765-9521
Fax Number	:

Authorized Official
Title or Position	:	NURSE PRACTITIONER
Name	:	LOCIANNA BLACKWELL
Credential	:	APRN
Telephone Number	:	954-765-9521

Provider Enumeration Date	:	02/28/2021
Last Update Date	:	02/28/2021

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Directions to “HYDRATION EXPERIENCE ” Practice Location

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