Basic Information
| Provider Information | |||||||||
| NPI: | 1427793181 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EXPRESS PROVIDER SERVICES PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8130 LAKEWOOD MAIN ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342025068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072211679 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8130 LAKEWOOD MAIN ST STE 103 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD RANCH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342025068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4072211679 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2022 | ||||||||
| LastUpdateDate: | 08/17/2022 | ||||||||
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| AuthorizedOfficialLastName: | RALEY | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4072211679 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | APRN | ||||||||
| NPICertificationDate: | 08/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 9298097 | 01 | FL | APRN LICENSE | OTHER |