Healthcare Provider Details

I. General information

NPI: 1922563030
Provider Name (Legal Business Name): ANDELL Y PHILLIP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2019
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 INTERNATIONAL PKWY STE 2000
LAKE MARY FL
32746-5096
US

IV. Provider business mailing address

8810 SW HIGHWAY 200 UNIT 124
OCALA FL
34481-7822
US

V. Phone/Fax

Practice location:
  • Phone: 352-502-4923
  • Fax: 352-504-0241
Mailing address:
  • Phone: 352-502-4923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number239577
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number166697
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: