Basic Information
| Provider Information | |||||||||
| NPI: | 1497239693 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALTA | ||||||||
| FirstName: | ENRILEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4301 N HABANA AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138795010 | ||||||||
| FaxNumber: | 8134438148 | ||||||||
| Practice Location | |||||||||
| Address1: | 4301 N HABANA AVE | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138795010 | ||||||||
| FaxNumber: | 8134438148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2018 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP9250767 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | APRN9250767 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 102215300 | 05 | FL | MEDICAID |