Provider Demographics
NPI:1518430032
Name:GOLDEN, TEQUILA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:TEQUILA
Middle Name:
Last Name:GOLDEN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5401 S KIRKMAN RD STE 310
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-7937
Mailing Address - Country:US
Mailing Address - Phone:800-721-8839
Mailing Address - Fax:407-386-6058
Practice Address - Street 1:5401 S KIRKMAN RD STE 310
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-7937
Practice Address - Country:US
Practice Address - Phone:800-721-8839
Practice Address - Fax:407-386-6058
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000106363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health