Healthcare Provider Details

I. General information

NPI: 1568915791
Provider Name (Legal Business Name): AUDREY L FITZGERALD PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2016
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4106 W LAKE MARY BLVD STE 212
LAKE MARY FL
32746-3344
US

IV. Provider business mailing address

661 E ALTAMONTE DR STE 231
ALTAMONTE SPRINGS FL
32701-5102
US

V. Phone/Fax

Practice location:
  • Phone: 407-333-2525
  • Fax:
Mailing address:
  • Phone: 407-303-5214
  • Fax: 407-303-5215

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9109822
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: