Provider Demographics
NPI:1124648639
Name:THEOBALD, ELEANOR (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ELEANOR
Middle Name:
Last Name:THEOBALD
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 NE 6TH ST UNIT 334
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-6407
Mailing Address - Country:US
Mailing Address - Phone:443-837-8805
Mailing Address - Fax:
Practice Address - Street 1:1010 S FEDERAL HWY STE 1010
Practice Address - Street 2:
Practice Address - City:DELRAY BEACH
Practice Address - State:FL
Practice Address - Zip Code:33483-5132
Practice Address - Country:US
Practice Address - Phone:561-413-9511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
FLPA9116006208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program