1346317047 NPI number — ALYSSA L MACCA APRN

Table of content: ALYSSA L MACCA APRN (NPI 1346317047)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346317047 NPI number — ALYSSA L MACCA APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MACCA
Provider First Name:
ALYSSA
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LIGUORI
Provider Other First Name:
ALYSSA
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1346317047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 917770
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32891-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5140 HIGHLANDS BY THE LAKE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKELAND
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33812-3083
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-640-8500
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/29/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  ARNP9204843 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01904 . This is a "UNIVERSAL" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 301304 . This is a "AVMED" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 200731387 . This is a "TRICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 37919Z . This is a "BCBS PROVIDER #" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: Y12VV . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 200731387 . This is a "HUMANA" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 269836600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: U7175X . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 309054000 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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