Healthcare Provider Details

I. General information

NPI: 1336483841
Provider Name (Legal Business Name): ANITA RAE CHILDERS RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANITA RAE CONLEY RD

II. Dates (important events)

Enumeration Date: 11/21/2012
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92 W MILLER ST
ORLANDO FL
32806-2032
US

IV. Provider business mailing address

92 W MILLER ST MP 317
ORLANDO FL
32806-2032
US

V. Phone/Fax

Practice location:
  • Phone: 321-841-2418
  • Fax: 407-649-3187
Mailing address:
  • Phone: 321-841-2418
  • Fax: 407-649-3187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberND5649
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND5649
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: