| Entity Name: | JAN D PHELPS, PA |
| Jurisdiction: | FLORIDA |
| Filing Type: | Domestic Profit |
| Status: | Active |
| Date Filed: | 01 Apr 2004 (21 years ago) |
| Document Number: | P04000056242 |
| FEI/EIN Number | 201049545 |
| Address: | 11014 Cinderlane Pl, TAMPA, FL, 33612, US |
| Mail Address: | P.O. Box 16292, TAMPA, FL, 33687, US |
| ZIP code: | 33612 |
| County: | Hillsborough |
| Place of Formation: | FLORIDA |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1326237850 | 2007-10-22 | 2011-05-17 | 1442 W BUSCH BLVD, TAMPA, FL, 336127602, US | 1442 W BUSCH BLVD, TAMPA, FL, 336127602, US | |||||||||||||||||||||||||||||||||||||||||||
|
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| Phone | +1 813-931-9094 |
| Fax | 8139351126 |
Authorized person
| Name | MRS. JAN DENICE PHELPS |
| Role | OWNER |
| Phone | 8139319094 |
Taxonomy
| Taxonomy Code | 363LF0000X - Family Nurse Practitioner |
| License Number | 1851392 |
| State | FL |
| Is Primary | Yes |
Other Provider Identifiers
| Issuer | BCBS |
| Number | Y031B |
| State | FL |
| Issuer | UPIN |
| Number | P62395 |
| State | FL |
| Issuer | LICENSE |
| Number | 1851392 |
| State | FL |
| Issuer | MEDICAID |
| Number | 305568000 |
| State | FL |
| Name | Role | Address |
|---|---|---|
| PHELPS JAN D | Agent | 11014 CINDERLANE PLACE, TAMPA, FL, 33617 |
| Name | Role | Address |
|---|---|---|
| PHELPS JAN D | President | 11014 CINDERLANE PLACE, TAMPA, FL, 33617 |
| Event Type | Filed Date | Value | Description |
|---|---|---|---|
| CHANGE OF PRINCIPAL ADDRESS | 2020-03-30 | 11014 Cinderlane Pl, TAMPA, FL 33612 | No data |
| CHANGE OF MAILING ADDRESS | 2020-03-30 | 11014 Cinderlane Pl, TAMPA, FL 33612 | No data |
| REGISTERED AGENT ADDRESS CHANGED | 2012-02-13 | 11014 CINDERLANE PLACE, TAMPA, FL 33617 | No data |
| Name | Date |
|---|---|
| ANNUAL REPORT | 2024-04-18 |
| ANNUAL REPORT | 2023-04-28 |
| ANNUAL REPORT | 2022-05-02 |
| ANNUAL REPORT | 2021-03-30 |
| ANNUAL REPORT | 2020-03-30 |
| ANNUAL REPORT | 2019-04-24 |
| ANNUAL REPORT | 2018-07-06 |
| ANNUAL REPORT | 2017-03-17 |
| ANNUAL REPORT | 2016-04-27 |
| ANNUAL REPORT | 2015-04-23 |
Date of last update: 01 Feb 2025
Sources: Florida Department of State
