Healthcare Provider Details

I. General information

NPI: 1538982566
Provider Name (Legal Business Name): FANESSA RYDER CPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2024
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 CORPORATE CT STE 104
FORT MYERS FL
33919-3513
US

IV. Provider business mailing address

14071 CEDARDALE ST
FORT MYERS FL
33905-7696
US

V. Phone/Fax

Practice location:
  • Phone: 239-340-1512
  • Fax:
Mailing address:
  • Phone: 239-340-1512
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246RP1900X
TaxonomyPhlebotomy Technician
License Number24R2157
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: