Provider Demographics
NPI:1306353776
Name:SUMMERVILLE, ROXANNE (NBC-HWC)
Entity type:Individual
Prefix:
First Name:ROXANNE
Middle Name:
Last Name:SUMMERVILLE
Suffix:
Gender:F
Credentials:NBC-HWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1064 N TAMIAMI TRL UNIT 1302
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34236-2475
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1064 N TAMIAMI TRL UNIT 1302
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34236-2475
Practice Address - Country:US
Practice Address - Phone:941-556-9055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-06
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171400000X
FL7341042083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine
No171400000XOther Service ProvidersHealth & Wellness Coach