Healthcare Provider Details

I. General information

NPI: 1962402735
Provider Name (Legal Business Name): BRENDA FAY AHMED LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1220 WILLIS AVE
DAYTONA BEACH FL
32114-2810
US

IV. Provider business mailing address

1220 WILLIS AVE
DAYTONA BEACH FL
32114-2810
US

V. Phone/Fax

Practice location:
  • Phone: 386-236-3200
  • Fax:
Mailing address:
  • Phone: 386-236-3200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN770761
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: