Healthcare Provider Details

I. General information

NPI: 1871907550
Provider Name (Legal Business Name): ANANTHALAKSHMI KRISHNAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

126 DEL PRADO BLVD N SUITE 101
CAPE CORAL FL
33909-2713
US

IV. Provider business mailing address

126 DEL PRADO BLVD N SUITE 101
CAPE CORAL FL
33909-2713
US

V. Phone/Fax

Practice location:
  • Phone: 239-772-3295
  • Fax: 239-772-5084
Mailing address:
  • Phone: 239-772-3295
  • Fax: 239-772-5084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME0057036
License Number StateFL

VIII. Authorized Official

Name: PATTY LAUX
Title or Position: MANAGER
Credential:
Phone: 239-772-3295