Provider Demographics
NPI:1639747140
Name:AMPUDIA LLANO, RAQUEL (NP)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:AMPUDIA LLANO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6132 OAK CLUSTER CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-2343
Mailing Address - Country:US
Mailing Address - Phone:813-325-4049
Mailing Address - Fax:
Practice Address - Street 1:6132 OAK CLUSTER CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-2343
Practice Address - Country:US
Practice Address - Phone:813-325-4049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-12
Last Update Date:2021-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11012384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty