Provider Demographics
NPI:1679167894
Name:HYDRATION EXPERIENCE
Entity Type:Organization
Organization Name:HYDRATION EXPERIENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LOCIANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACKWELL
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:954-765-9521
Mailing Address - Street 1:1329 NW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:DANIA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33004-2341
Mailing Address - Country:US
Mailing Address - Phone:954-765-9521
Mailing Address - Fax:
Practice Address - Street 1:1329 NW 10TH ST
Practice Address - Street 2:
Practice Address - City:DANIA BEACH
Practice Address - State:FL
Practice Address - Zip Code:33004-2341
Practice Address - Country:US
Practice Address - Phone:954-765-9521
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1356657704Medicaid