Provider Demographics
NPI: | 1821797622 |
---|---|
Name: | EHEALTH PROVISIONS, LLC |
Entity Type: | Organization |
Organization Name: | EHEALTH PROVISIONS, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | NURSE PRACTITIONER / PROVIDER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | KIM |
Authorized Official - Middle Name: | NGUYET |
Authorized Official - Last Name: | LILLY-BERNAU |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | AGPCNP-C |
Authorized Official - Phone: | 313-720-3358 |
Mailing Address - Street 1: | 54359 ALGONQUIN DR |
Mailing Address - Street 2: | |
Mailing Address - City: | SHELBY TOWNSHIP |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48315-1106 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 313-720-3358 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1435 S OSPREY AVE STE 200 |
Practice Address - Street 2: | |
Practice Address - City: | SARASOTA |
Practice Address - State: | FL |
Practice Address - Zip Code: | 34239-2905 |
Practice Address - Country: | US |
Practice Address - Phone: | 941-404-5453 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2023-03-01 |
Last Update Date: | 2023-04-17 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |