Healthcare Provider Details

I. General information

NPI: 1972077873
Provider Name (Legal Business Name): SHAELISA LASAINE CPE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/14/2019
Last Update Date: 01/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 MARTINWOOD DR
ORLANDO FL
32808-4940
US

IV. Provider business mailing address

PO BOX 547722
ORLANDO FL
32854-7722
US

V. Phone/Fax

Practice location:
  • Phone: 321-695-8597
  • Fax:
Mailing address:
  • Phone: 321-695-8597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: