Provider Demographics
NPI:1083936280
Name:PHELPS, ANN M (ARNP)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:M
Last Name:PHELPS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 MIDFLORIDA DR STE 1
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-4916
Mailing Address - Country:US
Mailing Address - Phone:863-701-7188
Mailing Address - Fax:863-701-2014
Practice Address - Street 1:619 MIDFLORIDA DR STE 1
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-4916
Practice Address - Country:US
Practice Address - Phone:863-701-7188
Practice Address - Fax:863-701-2014
Is Sole Proprietor?:No
Enumeration Date:2010-02-16
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9225667363LF0000X
FLARNP9225667363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005463300Medicaid
FLGC856ZMedicare UPIN