1366149957 NPI number — DANYALE LATRICE KIDD APRN

Table of content: DANYALE LATRICE KIDD APRN (NPI 1366149957)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366149957 NPI number — DANYALE LATRICE KIDD APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KIDD
Provider First Name:
DANYALE
Provider Middle Name:
LATRICE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOORE
Provider Other First Name:
DANYALE
Provider Other Middle Name:
LATRICE
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:
1366149957
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8333 N DAVIS HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32514-6050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-474-8200
Provider Business Mailing Address Fax Number:
850-474-8016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8333 N DAVIS HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32514-6050
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-474-8200
Provider Business Practice Location Address Fax Number:
850-474-8016
Provider Enumeration Date:
02/14/2023

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: 363LF0000X , with the licence number:  APRN11024351 , 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: 117299900 . 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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