Basic Information
| Provider Information | |||||||||
| NPI: | 1699084392 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | SANDRA | ||||||||
| MiddleName: | PATRICIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORA | ||||||||
| OtherFirstName: | SANDRA | ||||||||
| OtherMiddleName: | PATRICIA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4200 N ARMENIA AVE | ||||||||
| Address2: | STE 1 | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336076438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139223703 | ||||||||
| FaxNumber: | 8138728978 | ||||||||
| Practice Location | |||||||||
| Address1: | 4915 EHRLICH RD | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336242038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139602400 | ||||||||
| FaxNumber: | 8139602410 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2010 | ||||||||
| LastUpdateDate: | 09/17/2013 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | ARNP3287112 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 1372292 | 01 | COVENTRY | OTHER | 9393932 | 01 | FL | AETNA | OTHER | 38909 | 01 | BLUE CROSS | OTHER | 363022 | 01 | FL | AVMED | OTHER |