1770971343 NPI number — MRS. ALISSA GWEN LEDGERWOOD ARNP

Table of content: MRS. ALISSA GWEN LEDGERWOOD ARNP (NPI 1770971343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770971343 NPI number — MRS. ALISSA GWEN LEDGERWOOD ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEDGERWOOD
Provider First Name:
ALISSA
Provider Middle Name:
GWEN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
ARNP
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:
1770971343
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3160 SOUTHGATE COMMERCE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32806-8549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-859-4540
Provider Business Mailing Address Fax Number:
407-859-3815

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1646 33RD ST
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32839-8866
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-409-8118
Provider Business Practice Location Address Fax Number:
407-264-6562
Provider Enumeration Date:
01/05/2015

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:  ARNP9251745 , 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: 116452100 . 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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