Provider Demographics
NPI:1710310768
Name:THEOBALD, TINA N (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:N
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 W BAKER ST
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33563-2851
Mailing Address - Country:US
Mailing Address - Phone:813-752-1336
Mailing Address - Fax:813-754-6914
Practice Address - Street 1:3302 W BAKER ST
Practice Address - Street 2:
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33563-2851
Practice Address - Country:US
Practice Address - Phone:813-752-1336
Practice Address - Fax:813-754-6914
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9268946363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHP558ZMedicare PIN