Provider Demographics
NPI:1053303537
Name:THEOBALDS, PAULINE ROZELLE (CNM)
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:ROZELLE
Last Name:THEOBALDS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 N KENDALL DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1483
Mailing Address - Country:US
Mailing Address - Phone:305-270-7999
Mailing Address - Fax:305-270-6788
Practice Address - Street 1:10700 N KENDALL DR STE 200
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176
Practice Address - Country:US
Practice Address - Phone:305-270-7999
Practice Address - Fax:305-270-6788
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2725772367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL340448000Medicaid
FL340448000Medicaid
FLE2339XMedicare PIN