Provider Demographics
NPI:1801597422
Name:SUMMERVILLE, COURTNEY B'NAI (CEO)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:B'NAI
Last Name:SUMMERVILLE
Suffix:
Gender:F
Credentials:CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 611
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639-0611
Mailing Address - Country:US
Mailing Address - Phone:813-459-1012
Mailing Address - Fax:
Practice Address - Street 1:11422 TULANE ST
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34654-2301
Practice Address - Country:US
Practice Address - Phone:813-459-1012
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-10
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL239016374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide