Provider Demographics
NPI:1417847492
Name:RETALIC, AILISSA TEKLA (APRN)
Entity type:Individual
Prefix:
First Name:AILISSA
Middle Name:TEKLA
Last Name:RETALIC
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1826 WHIPPOORWILL LN
Mailing Address - Street 2:
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32720-2103
Mailing Address - Country:US
Mailing Address - Phone:386-490-7537
Mailing Address - Fax:386-490-7537
Practice Address - Street 1:1826 WHIPPOORWILL LN
Practice Address - Street 2:
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32720-2103
Practice Address - Country:US
Practice Address - Phone:386-490-7537
Practice Address - Fax:386-490-7537
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-09
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11040778363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health