MEDICARE: EXTRACARE & WELLNESS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207QA0505X	Adult Medicine Physician

General Provider Information

NPI Number	:	1417501040
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXTRACARE & WELLNESS LLC

Provider Business Mailing Address
First Line	:	1410 N PINE HILLS RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32808-4408
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1410 N PINE HILLS RD
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32808-4408
Country	:	US
Telephone Number	:	321-246-5358
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KETTIA CADET CHERENFANT
Credential	:	DNP
Telephone Number	:	321-246-5358

Provider Enumeration Date	:	07/31/2019
Last Update Date	:	07/15/2021

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Directions to “EXTRACARE & WELLNESS LLC ” Practice Location

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