Provider Demographics
NPI:1548239874
Name:PURCELL, THERESA ANN (ARNP-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ANN
Last Name:PURCELL
Suffix:
Gender:F
Credentials:ARNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:695 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114
Mailing Address - Country:US
Mailing Address - Phone:386-258-8722
Mailing Address - Fax:386-258-8659
Practice Address - Street 1:695 N CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114
Practice Address - Country:US
Practice Address - Phone:386-258-8722
Practice Address - Fax:386-258-8659
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2010-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP866892363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303870000Medicaid
FL303870000Medicaid
S84762Medicare UPIN