Provider Demographics
NPI:1457729451
Name:TA, PHOENIX (APRN)
Entity Type:Individual
Prefix:
First Name:PHOENIX
Middle Name:
Last Name:TA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 S ORANGE AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32809-3039
Mailing Address - Country:US
Mailing Address - Phone:407-901-1808
Mailing Address - Fax:
Practice Address - Street 1:5105 S ORANGE AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-3039
Practice Address - Country:US
Practice Address - Phone:407-901-1808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-08
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9349473363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner