Healthcare Provider Details

I. General information

NPI: 1972416337
Provider Name (Legal Business Name): ANNALIECE BALENSIEFEN CNM, WHNP-BC, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2026
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

182 HOLDERNESS DR
LONGWOOD FL
32779-5725
US

IV. Provider business mailing address

182 HOLDERNESS DR
LONGWOOD FL
32779-5725
US

V. Phone/Fax

Practice location:
  • Phone: 815-878-9636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number104199230
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number10795
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: