Provider Demographics
NPI:1174755631
Name:SPA BELIZIMA
Entity type:Organization
Organization Name:SPA BELIZIMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:ANN-MARIE
Authorized Official - Middle Name:SHERRY
Authorized Official - Last Name:HARRIS-POLANCO
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:813-751-5691
Mailing Address - Street 1:7603 GUNN HWY STE D
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33625-3164
Mailing Address - Country:US
Mailing Address - Phone:813-751-5691
Mailing Address - Fax:866-422-1671
Practice Address - Street 1:7603 GUNN HWY STE D
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33625-3164
Practice Address - Country:US
Practice Address - Phone:813-751-5691
Practice Address - Fax:866-422-1671
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPA BELIZIMA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-18
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL080609251J00000X
261QP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No251J00000XAgenciesNursing Care
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care