Healthcare Provider Details

I. General information

NPI: 1124772520
Provider Name (Legal Business Name): PAULETTE ANNMARIE ANNIKEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2022
Last Update Date: 02/05/2022
Certification Date: 02/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 EAGLE DR
KISSIMMEE FL
34759-4432
US

IV. Provider business mailing address

415 EAGLE DR
KISSIMMEE FL
34759-4432
US

V. Phone/Fax

Practice location:
  • Phone: 863-547-4886
  • Fax: 863-547-4993
Mailing address:
  • Phone: 863-547-4886
  • Fax: 863-547-4993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number692345396
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number692345396
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: