Provider Demographics
NPI:1093106387
Name:TATE, NEFERTITI (DIRECTOR)
Entity Type:Individual
Prefix:
First Name:NEFERTITI
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:DIRECTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 25TH DR E STE 1
Mailing Address - Street 2:
Mailing Address - City:ELLENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34222-2054
Mailing Address - Country:US
Mailing Address - Phone:941-981-5342
Mailing Address - Fax:941-981-5351
Practice Address - Street 1:945 25TH DR E STE 1
Practice Address - Street 2:
Practice Address - City:ELLENTON
Practice Address - State:FL
Practice Address - Zip Code:34222-2054
Practice Address - Country:US
Practice Address - Phone:941-981-5342
Practice Address - Fax:941-981-5351
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X, 347C00000X
FL233808376J00000X, 372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No347C00000XTransportation ServicesPrivate Vehicle
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL233808OtherSTATE LICENSE
FL233951OtherSTATE LICENSE