Provider Demographics
NPI:1093477895
Name:BIETOLA, TRESA (FNP)
Entity Type:Individual
Prefix:
First Name:TRESA
Middle Name:
Last Name:BIETOLA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TRESA
Other - Middle Name:
Other - Last Name:HAGELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:3562 SOUTHERN ORCHARD RD W
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-6900
Mailing Address - Country:US
Mailing Address - Phone:519-980-7667
Mailing Address - Fax:
Practice Address - Street 1:2450 HOLLYWOOD BLVD STE 701
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33020-6628
Practice Address - Country:US
Practice Address - Phone:954-367-5316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11015567363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner