Healthcare Provider Details

I. General information

NPI: 1891517322
Provider Name (Legal Business Name): NAOMI PLACK
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2024
Last Update Date: 10/28/2024
Certification Date: 10/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2627 W EAU GALLIE BLVD STE 101
MELBOURNE FL
32935-8303
US

IV. Provider business mailing address

N1637 HIGHWAY 67
NEOSHO WI
53059-9645
US

V. Phone/Fax

Practice location:
  • Phone: 321-837-3820
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: