Basic Information
| Provider Information | |||||||||
| NPI: | 1124592811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FIESTAN | ||||||||
| FirstName: | GILAINE | ||||||||
| MiddleName: | |||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 851 TRAFALGAR CT STE 200E | ||||||||
| Address2: | |||||||||
| City: | MAITLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327517420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076670444 | ||||||||
| FaxNumber: | 4076674338 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 E ROLLINS ST | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328031248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4076670444 | ||||||||
| FaxNumber: | 4076674338 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2019 | ||||||||
| LastUpdateDate: | 01/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 95033114 | CA | N | Nursing Service Providers | Registered Nurse | 367500000X | APRN11002919 | FL | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 163W00000X | 9331382 | FL | N | Nursing Service Providers | Registered Nurse |
ID Information
| ID | Type | State | Issuer | Description | 103425400 | 05 | FL | MEDICAID |