1104392448 NPI number — WENDY JANE LADER

Table of content: WENDY JANE LADER (NPI 1104392448)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104392448 NPI number — WENDY JANE LADER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LADER
Provider First Name:
WENDY
Provider Middle Name:
JANE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1104392448
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2775 NW 49TH AVE # 205-143
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCALA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34482-6212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-480-2797
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3002 SE 1ST AVE STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OCALA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34471-0407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-251-2600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/14/2018

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: 103TC0700X , with the licence number:  PY9666 , 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)