Provider Demographics
NPI:1497239693
Name:ALTA, ENRILEN (APRN-C)
Entity Type:Individual
Prefix:MRS
First Name:ENRILEN
Middle Name:
Last Name:ALTA
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 N HABANA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6546
Mailing Address - Country:US
Mailing Address - Phone:813-879-5010
Mailing Address - Fax:813-443-8148
Practice Address - Street 1:4301 N HABANA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6546
Practice Address - Country:US
Practice Address - Phone:813-879-5010
Practice Address - Fax:813-443-8148
Is Sole Proprietor?:No
Enumeration Date:2018-09-24
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9250767363LF0000X
FLAPRN9250767363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102215300Medicaid