Provider Demographics
NPI:1275963662
Name:GENERATIONSPAN HEALTHCARE LLC
Entity Type:Organization
Organization Name:GENERATIONSPAN HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:FLORENCE
Authorized Official - Middle Name:PEDATIN
Authorized Official - Last Name:BAMGBOSE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD ARNP
Authorized Official - Phone:850-264-9070
Mailing Address - Street 1:6271 WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32311-8526
Mailing Address - Country:US
Mailing Address - Phone:850-264-9070
Mailing Address - Fax:
Practice Address - Street 1:400 CAPITAL CIR SE STE 18128
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-3802
Practice Address - Country:US
Practice Address - Phone:850-264-9070
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-21
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3314182363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305043200Medicaid