Provider Demographics
NPI:1700640158
Name:DEWALT, ERICA
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:
Last Name:DEWALT
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 1:14606 MIRASOL MANOR CT
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-3311
Mailing Address - Country:US
Mailing Address - Phone:717-324-5679
Mailing Address - Fax:
Practice Address - Street 1:14606 MIRASOL MANOR CT
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-3311
Practice Address - Country:US
Practice Address - Phone:717-324-5679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider