Provider Demographics
NPI:1184293201
Name:FONSECA PORTELLES, SAILIN
Entity type:Individual
Prefix:MS
First Name:SAILIN
Middle Name:
Last Name:FONSECA PORTELLES
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 1:1400 NW 107TH AVE STE 500
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33172-2746
Mailing Address - Country:US
Mailing Address - Phone:813-648-6684
Mailing Address - Fax:
Practice Address - Street 1:6726 HANLEY RD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-4739
Practice Address - Country:US
Practice Address - Phone:813-284-7903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-22
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLF06210386363LF0000X
FLAPRN11014304363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily