1386674505 NPI number — PEGGY LADD ARNP

Table of content: PEGGY LADD ARNP (NPI 1386674505)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386674505 NPI number — PEGGY LADD ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LADD
Provider First Name:
PEGGY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1386674505
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
911 S MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRENTON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32693-3239
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-463-6292
Provider Business Mailing Address Fax Number:
352-463-4507

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
821 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRENTON
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32693-3238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-463-6292
Provider Business Practice Location Address Fax Number:
352-463-4507
Provider Enumeration Date:
07/04/2006

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: 363LP0200X , with the licence number:  ARNP1569032 , 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: 58539 . This is a "BC" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: ARNP1569032 . This is a "MEDICAL LICENSE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 307483800 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 018795600 . 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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