Provider Demographics
NPI:1891579785
Name:OLEMBO, SALLY E
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:E
Last Name:OLEMBO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:E
Other - Last Name:OLEMBO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:2114 HARRIS HAWK AVE
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-4965
Mailing Address - Country:US
Mailing Address - Phone:302-218-8502
Mailing Address - Fax:
Practice Address - Street 1:11464 N 53RD ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617-2216
Practice Address - Country:US
Practice Address - Phone:813-914-7772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11026011363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily