Basic Information
| Provider Information | |||||||||
| NPI: | 1104914845 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOND-ROZELLE | ||||||||
| FirstName: | AMY | ||||||||
| MiddleName: | VIRGINIA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, APRN-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOND | ||||||||
| OtherFirstName: | AMY | ||||||||
| OtherMiddleName: | VIRGINIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | APRN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5130 SUNFOREST DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336346327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278240780 | ||||||||
| FaxNumber: | 8135148891 | ||||||||
| Practice Location | |||||||||
| Address1: | 5130 SUNFOREST DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336346327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7278240780 | ||||||||
| FaxNumber: | 8135148891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2129792 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 308945200 | 05 | FL | MEDICAID |