Provider Demographics
NPI:1235369174
Name:THEISS, DONNA FAYE (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:FAYE
Last Name:THEISS
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 1:1425 S US 301
Mailing Address - Street 2:
Mailing Address - City:SUMTERVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:33585-5141
Mailing Address - Country:US
Mailing Address - Phone:352-793-5900
Mailing Address - Fax:352-793-8050
Practice Address - Street 1:1700 N MCMULLEN BOOTH RD
Practice Address - Street 2:SUITE D1
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33759-2130
Practice Address - Country:US
Practice Address - Phone:352-671-6788
Practice Address - Fax:352-672-2291
Is Sole Proprietor?:No
Enumeration Date:2009-07-24
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9287302363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY04RUOtherBCBS
FL002826300Medicaid
FL002826300Medicaid