1225621808 NPI number — LIBBIE DENISE FLETCHER RDH

Table of content: LIBBIE DENISE FLETCHER RDH (NPI 1225621808)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225621808 NPI number — LIBBIE DENISE FLETCHER RDH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLETCHER
Provider First Name:
LIBBIE
Provider Middle Name:
DENISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RDH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GOODWIN
Provider Other First Name:
LIBBIE
Provider Other Middle Name:
DENISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1225621808
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2804 REMINGTON GREEN CIR STE 2
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TALLAHASSEE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32308-1550
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-385-4494
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1249 STRONG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
QUINCY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32351-5248
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-875-9502
Provider Business Practice Location Address Fax Number:
850-627-2786
Provider Enumeration Date:
02/16/2021

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: 124Q00000X , with the licence number:  7761 , 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: 124Q00000X , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7761 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 110037500 . 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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