1003274473 NPI number — CARLY DELBERT FIORAMANTI APRN

Table of content: CARLY DELBERT FIORAMANTI APRN (NPI 1003274473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003274473 NPI number — CARLY DELBERT FIORAMANTI APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FIORAMANTI
Provider First Name:
CARLY
Provider Middle Name:
DELBERT
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:
DELBERT
Provider Other First Name:
CARLY
Provider Other Middle Name:
BETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1003274473
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
276 S HUNTLEY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE PLACID
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33852-6978
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:
13 N MAIN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE PLACID
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33852-2603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
863-659-1079
Provider Business Practice Location Address Fax Number:
863-659-1317
Provider Enumeration Date:
02/01/2016

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: 363LA2200X , with the licence number:  APRN9302815 , 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: 016664500 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: DQEAD . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 016664500 . 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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