Healthcare Provider Details

I. General information

NPI: 1376052993
Provider Name (Legal Business Name): CECILIE LOUISE COCKRIEL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CECILIE LOUISE PRAVDICA PA-C

II. Dates (important events)

Enumeration Date: 09/26/2017
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 DON WICKHAM DR STE 125
CLERMONT FL
34711-1979
US

IV. Provider business mailing address

1900 DON WICKHAM DR STE 125
CLERMONT FL
34711-1979
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-7856
  • Fax: 321-841-1378
Mailing address:
  • Phone: 321-841-7856
  • Fax: 321-841-1378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9110729
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9110729
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: