Provider Demographics
NPI:1356000533
Name:FREEMAN, TAVIS A (LPN)
Entity Type:Individual
Prefix:
First Name:TAVIS
Middle Name:A
Last Name:FREEMAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 19TH ST W
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34207-3201
Mailing Address - Country:US
Mailing Address - Phone:941-212-8821
Mailing Address - Fax:
Practice Address - Street 1:5520 19TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34207-3201
Practice Address - Country:US
Practice Address - Phone:941-212-8821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5153636164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse