Provider Demographics
NPI:1699398461
Name:TELIBASA, KERRI LYNN
Entity Type:Individual
Prefix:
First Name:KERRI
Middle Name:LYNN
Last Name:TELIBASA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:92 W MILLER ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-2032
Mailing Address - Country:US
Mailing Address - Phone:407-267-3484
Mailing Address - Fax:
Practice Address - Street 1:92 W MILLER ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-2032
Practice Address - Country:US
Practice Address - Phone:407-267-3484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-27
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007244363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care