Healthcare Provider Details

I. General information

NPI: 1194297291
Provider Name (Legal Business Name): JUDY ANN ALONSO-SLUSARZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2018
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 LAKE LUCIEN DR STE 112
MAITLAND FL
32751-7233
US

IV. Provider business mailing address

500 KIRTS BLVD STE 100
TROY MI
48084-4135
US

V. Phone/Fax

Practice location:
  • Phone: 321-207-9029
  • Fax: 844-410-7960
Mailing address:
  • Phone: 248-434-6169
  • Fax: 855-618-6655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9172348
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9172348
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: