1841829157 NPI number — HEATHER POUND ABOULHOSN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841829157 NPI number — HEATHER POUND ABOULHOSN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABOULHOSN
Provider First Name:
HEATHER
Provider Middle Name:
POUND
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THOMPSON
Provider Other First Name:
HEATHER
Provider Other Middle Name:
POUND
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:
1841829157
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2565 JUDGE FRAN JAMIESON WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VIERA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32940-5998
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-634-3688
Provider Business Mailing Address Fax Number:
321-504-0955

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2565 JUDGE FRAN JAMIESON WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VIERA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32940-5998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-634-3688
Provider Business Practice Location Address Fax Number:
321-504-0955
Provider Enumeration Date:
04/07/2020

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: 222Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108909500 . 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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