Provider Demographics
NPI:1386178739
Name:THE CHILDRENS DOCTOR OF TAMPABAY, JACQUELIN ENIEBLES MD, PLLC
Entity Type:Organization
Organization Name:THE CHILDRENS DOCTOR OF TAMPABAY, JACQUELIN ENIEBLES MD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:MARIA
Authorized Official - Last Name:NIEBLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-481-8075
Mailing Address - Street 1:1375 INDIAN TRAILS NORTH
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683
Mailing Address - Country:US
Mailing Address - Phone:727-481-8075
Mailing Address - Fax:
Practice Address - Street 1:14499 NORTH DALE MABRY HWY, SUITE 180-S
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:34683
Practice Address - Country:US
Practice Address - Phone:727-481-8075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-12
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME66997208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty