Provider Demographics
NPI:1457001992
Name:PROVEAUX, RACHAEL
Entity Type:Individual
Prefix:
First Name:RACHAEL
Middle Name:
Last Name:PROVEAUX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RACHAEL
Other - Middle Name:
Other - Last Name:TOMBOLESI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8422 TAMPA POINT BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33621-1405
Mailing Address - Country:US
Mailing Address - Phone:843-908-4438
Mailing Address - Fax:
Practice Address - Street 1:3003 TEXAS TRAIL LN
Practice Address - Street 2:
Practice Address - City:MANVEL
Practice Address - State:TX
Practice Address - Zip Code:77578-3263
Practice Address - Country:US
Practice Address - Phone:843-908-4438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-27
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021125363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily