1891540779 NPI number — OTELIAH ANN MARIE CARTER SHERWOOD

Table of content: OTELIAH ANN MARIE CARTER SHERWOOD (NPI 1891540779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891540779 NPI number — OTELIAH ANN MARIE CARTER SHERWOOD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARTER SHERWOOD
Provider First Name:
OTELIAH
Provider Middle Name:
ANN MARIE
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:
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:
1891540779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5368 MACOON WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTLAKE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33470-7059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-394-0705
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4890 N STATE ROAD 7
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COCONUT CREEK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33073-3303
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-379-3528
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2024

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:  11032318 , 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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