Healthcare Provider Details

I. General information

NPI: 1942622998
Provider Name (Legal Business Name): JESSE ALBATROSOV
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2014
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 S PALMETTO AVE
DAYTONA BEACH FL
32114-4387
US

IV. Provider business mailing address

119 S PALMETTO AVE
DAYTONA BEACH FL
32114-4387
US

V. Phone/Fax

Practice location:
  • Phone: 386-562-8213
  • Fax:
Mailing address:
  • Phone: 386-562-8213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberALPP-29291
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: