Provider Demographics
NPI:1760036859
Name:EPIFANI LLC
Entity Type:Organization
Organization Name:EPIFANI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:URSULA
Authorized Official - Middle Name:
Authorized Official - Last Name:NKWANTABISA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:850-687-7890
Mailing Address - Street 1:1704 CARTIER PL
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-5730
Mailing Address - Country:US
Mailing Address - Phone:850-687-7890
Mailing Address - Fax:
Practice Address - Street 1:1704 CARTIER PL
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-5730
Practice Address - Country:US
Practice Address - Phone:850-687-7890
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-28
Last Update Date:2019-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL103096400Medicaid