Healthcare Provider Details

I. General information

NPI: 1336259852
Provider Name (Legal Business Name): ANN M CLEMENTS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANN LIDOSKI

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2915 LAKEVIEW DR STE 2021
FERN PARK FL
32730-2056
US

IV. Provider business mailing address

151 SOUTHHALL LN STE 300
MAITLAND FL
32751-7176
US

V. Phone/Fax

Practice location:
  • Phone: 866-400-3376
  • Fax: 407-788-8834
Mailing address:
  • Phone: 866-400-3376
  • Fax: 407-650-3455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2529
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: