Provider Demographics
NPI:1316349731
Name:BALLESTEROS, TONI H (ARNP)
Entity type:Individual
Prefix:MRS
First Name:TONI
Middle Name:H
Last Name:BALLESTEROS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:TONI
Other - Middle Name:LYNN
Other - Last Name:HEIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:109 W KNAPP AVE
Mailing Address - Street 2:
Mailing Address - City:EDGEWATER
Mailing Address - State:FL
Mailing Address - Zip Code:32132-1555
Mailing Address - Country:US
Mailing Address - Phone:386-427-4544
Mailing Address - Fax:386-427-8688
Practice Address - Street 1:1431 ORANGE CAMP RD
Practice Address - Street 2:SUITE 115
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-7768
Practice Address - Country:US
Practice Address - Phone:386-427-4544
Practice Address - Fax:386-427-8688
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9331896363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLHZ649ZMedicare PIN