Healthcare Provider Details

I. General information

NPI: 1093474025
Provider Name (Legal Business Name): NIGHT LITE PEDIATRIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2021
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 W LAKE MARY BLVD
LAKE MARY FL
32746-6159
US

IV. Provider business mailing address

1 HOLLOW LANE SUITE 301
LAKE SUCCESS NY
11042
US

V. Phone/Fax

Practice location:
  • Phone: 407-585-0568
  • Fax:
Mailing address:
  • Phone: 516-207-7936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE MARIE LOPEZ
Title or Position: MANAGER OF CREDENTIALING AND ENROL
Credential:
Phone: 516-207-7936