Provider Demographics
NPI:1053826297
Name:DACOSTA-GREEN, OPHELIA (APRN)
Entity Type:Individual
Prefix:
First Name:OPHELIA
Middle Name:
Last Name:DACOSTA-GREEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6311 NW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MARGATE
Mailing Address - State:FL
Mailing Address - Zip Code:33063-5156
Mailing Address - Country:US
Mailing Address - Phone:954-592-7947
Mailing Address - Fax:
Practice Address - Street 1:2217 NORTH BLVD W
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:FL
Practice Address - Zip Code:33837-8990
Practice Address - Country:US
Practice Address - Phone:863-421-3456
Practice Address - Fax:863-421-3466
Is Sole Proprietor?:No
Enumeration Date:2017-12-11
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9199962363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLNP9199962OtherFNP CERTIFICATION NUMBER