1366421059 NPI number — MRS. TATIANA WELLENS PICOT DPM, PHD

Table of content: MRS. TATIANA WELLENS PICOT DPM, PHD (NPI 1366421059)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366421059 NPI number — MRS. TATIANA WELLENS PICOT DPM, PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PICOT
Provider First Name:
TATIANA
Provider Middle Name:
WELLENS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DPM, PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WELLENS-BRUSCHAYT
Provider Other First Name:
TATIANA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366421059
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 6TH ST NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINTER HAVEN
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33881-4630
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-299-4551
Provider Business Mailing Address Fax Number:
863-299-2310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 6TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINTER HAVEN
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33881-4630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-299-4551
Provider Business Practice Location Address Fax Number:
863-299-2310
Provider Enumeration Date:
01/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  PO2760 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7741073 . This is a "AETNA PROVIDER #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 65624 . This is a "BCBS PROVIDER#" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: PO2760 . This is a "FLORIDA LICENSE NUMBER" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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