1255437646 NPI number — DENISE ANDRADE PA

Table of content: DENISE ANDRADE PA (NPI 1255437646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255437646 NPI number — DENISE ANDRADE PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ANDRADE
Provider First Name:
DENISE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1255437646
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/26/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2401 FRIST BLVD
Provider Second Line Business Mailing Address:
#7,9, AND 10
Provider Business Mailing Address City Name:
FORT PIERCE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34950-4800
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
772-466-0088
Provider Business Mailing Address Fax Number:
772-460-8555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3500 TYLER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOLLYWOOD
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33021-6852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-987-2047
Provider Business Practice Location Address Fax Number:
954-987-2048
Provider Enumeration Date:
09/15/2006

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: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 291474300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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