1659510790 NPI number — MS. LA-VON JULIE LANDIS CASE MANAGER

Table of content: MS. LA-VON JULIE LANDIS CASE MANAGER (NPI 1659510790)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659510790 NPI number — MS. LA-VON JULIE LANDIS CASE MANAGER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LANDIS
Provider First Name:
LA-VON
Provider Middle Name:
JULIE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CASE MANAGER
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659510790
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
224 SE 24TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32641-7516
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-334-7902
Provider Business Mailing Address Fax Number:
352-955-2126

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
224 SE 24TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GAINESVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32641-7516
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-334-7902
Provider Business Practice Location Address Fax Number:
352-955-2126
Provider Enumeration Date:
02/12/2009

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000533700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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