1770929994 NPI number — SHERONDA DENISE DRISDOM MSN, ARNP, AOCNP

Table of content: SHERONDA DENISE DRISDOM MSN, ARNP, AOCNP (NPI 1770929994)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770929994 NPI number — SHERONDA DENISE DRISDOM MSN, ARNP, AOCNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DRISDOM
Provider First Name:
SHERONDA
Provider Middle Name:
DENISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSN, ARNP, AOCNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BROWN
Provider Other First Name:
SHERONDA
Provider Other Middle Name:
DENISE
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:
1770929994
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4371 VERONICA S SHOEMAKER BLVD
Provider Second Line Business Mailing Address:
ATTN: CREDENTIALING DEPT
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33916-2216
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-274-8200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3730 7TH TERRACE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
VERO BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32960-6556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
772-581-0528
Provider Business Practice Location Address Fax Number:
772-581-0535
Provider Enumeration Date:
05/14/2013

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: 363L00000X , with the licence number:  ARNP 9185762 , 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: 017341700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com