Healthcare Provider Details

I. General information

NPI: 1720655780
Provider Name (Legal Business Name): ACADEMIC ALLIANCE IN DERMATOLOGY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2021
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13910 FIVAY RD STE 5
HUDSON FL
34667-7130
US

IV. Provider business mailing address

PO BOX 23329
NEW YORK NY
10087-3329
US

V. Phone/Fax

Practice location:
  • Phone: 727-259-7930
  • Fax: 727-935-0505
Mailing address:
  • Phone:
  • Fax: 410-883-0876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE PROFFITT
Title or Position: DIRECTOR OF ENROLLMENT & CREDENTIAL
Credential:
Phone: 804-869-6269