Provider Demographics
NPI:1922880111
Name:ECCLES, KEITHLYN C (AGACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KEITHLYN
Middle Name:C
Last Name:ECCLES
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:KEITHLYN
Other - Middle Name:C
Other - Last Name:WHARWOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AUSTIN
Mailing Address - Street 1:4712 SW 185TH AVE # A
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33029-6226
Mailing Address - Country:US
Mailing Address - Phone:305-762-2103
Mailing Address - Fax:
Practice Address - Street 1:4712 SW 185TH AVE # A
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33029-6226
Practice Address - Country:US
Practice Address - Phone:305-762-2103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-20
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL928-896363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care