Provider Demographics
NPI:1881194595
Name:AUGUSTIN, IMMACULA
Entity Type:Individual
Prefix:
First Name:IMMACULA
Middle Name:
Last Name:AUGUSTIN
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 1:5711 N NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-7125
Mailing Address - Country:US
Mailing Address - Phone:813-270-1013
Mailing Address - Fax:813-512-8926
Practice Address - Street 1:5711 N NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-7125
Practice Address - Country:US
Practice Address - Phone:813-270-1013
Practice Address - Fax:813-512-8926
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-19
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLA223-400-70-803-1376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker