1699138446 NPI number — DR. AMANDA ELAYNE HANEKOM MD

Table of content: DR. AMANDA ELAYNE HANEKOM MD (NPI 1699138446)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699138446 NPI number — DR. AMANDA ELAYNE HANEKOM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANEKOM
Provider First Name:
AMANDA
Provider Middle Name:
ELAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FARMER
Provider Other First Name:
AMANDA
Provider Other Middle Name:
ELAYNE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1699138446
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/30/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2454 WESTMINSTER TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVIEDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32765-7503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-276-5150
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2454 WESTMINSTER TER
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OVIEDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32765-7503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-276-5150
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/30/2016

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208100000X , with the licence number: ME145987 , 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: 108217000 . 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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