1336234673 NPI number — MRS. ADRIENNE LEE DAISERNIA P.T.

Table of content: MRS. ADRIENNE LEE DAISERNIA P.T. (NPI 1336234673)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336234673 NPI number — MRS. ADRIENNE LEE DAISERNIA P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAISERNIA
Provider First Name:
ADRIENNE
Provider Middle Name:
LEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1336234673
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11605 SAND CASTLE LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PANAMA CITY BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32407-4547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-532-9051
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 N RICHARD JACKSON BLVD
Provider Second Line Business Practice Location Address:
SUITE 30
Provider Business Practice Location Address City Name:
PANAMA CITY BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32407-2521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-235-6360
Provider Business Practice Location Address Fax Number:
850-235-8871
Provider Enumeration Date:
10/03/2006

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: 225100000X , with the licence number:  PT18733 , 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)





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