1447347992 NPI number — MRS. ANNIE CLARA WIDEMOND C.PH.T.

Table of content: MRS. ANNIE CLARA WIDEMOND C.PH.T. (NPI 1447347992)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447347992 NPI number — MRS. ANNIE CLARA WIDEMOND C.PH.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WIDEMOND
Provider First Name:
ANNIE
Provider Middle Name:
CLARA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
C.PH.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:
1447347992
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
507 GRISSHOLM ST
Provider Second Line Business Mailing Address:
P. O. BOX 1192
Provider Business Mailing Address City Name:
MACCLENNY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32063-2613
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-259-6785
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1436 STATE ROAD 121 SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MACCLENNY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32063
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-259-5868
Provider Business Practice Location Address Fax Number:
904-259-5275
Provider Enumeration Date:
10/06/2006

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: 183700000X , with the licence number:  2901-0104-0756-923 , 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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