Healthcare Provider Details

I. General information

NPI: 1831718980
Provider Name (Legal Business Name): INDIVIDUAL EDUCATION PLAN ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2020
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 MICHIGAN AVE
KISSIMMEE FL
34744-3567
US

IV. Provider business mailing address

1515 MICHIGAN AVE
KISSIMMEE FL
34744-3567
US

V. Phone/Fax

Practice location:
  • Phone: 407-485-1103
  • Fax:
Mailing address:
  • Phone: 407-485-1103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: MRS. SUSY ROSANNA BANKS
Title or Position: DIRECTOR OF STUDENT SERVICES
Credential:
Phone: 407-485-1103