Sandra Palmer

 
 2014 Sep 22 04:45 PM 
 TO: 16103548946 FROM: 8344150968 
 Page: 90 
 Advanced Rx 
 360 Ortho and Spine 
 Stefan Prada, MD 
 Optimizing Provider Care鈩 
 DEA # BP3793696 
 11809 N Dale Mabry Hwy 
 Tampa, FL 33618 
 Patient Name: Sandra Palmer
 DOB: 1992 Mar 27 DOI: 2021 Aug 10
 Address: 1119 CR 457 Lake Danasoffhee FC 33538 
 ICD-10: HS4.2 

 Physician Signature: 
 RO, 
 Date: 2021 Apr 22
 (MM/DD/YYYY) 
 Patient Signature: Pam Pennington 
 2018 Jul 14
 Date: 
 (MM/DD/YYYY) 
 www.Advanced-Rx.com I Phone 88844150 I Fax 92544150
 2430 Camino Ramon, Suite 120, San Ramon, CA 94556
