Healthcare Provider Details

I. General information

NPI: 1982198586
Provider Name (Legal Business Name): LETITIA M LANDIS AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LETITIA M KRIEG

II. Dates (important events)

Enumeration Date: 06/18/2018
Last Update Date: 07/20/2022
Certification Date: 07/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 GATEWAY DR STE 1E
MELBOURNE FL
32901-2607
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-984-3855
  • Fax: 321-984-8483
Mailing address:
  • Phone: 321-984-3855
  • Fax: 321-951-7408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAY2185
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: