Healthcare Provider Details

I. General information

NPI: 1225271885
Provider Name (Legal Business Name): CONNIE AILEEN FAUNTLEROY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2009
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 S SEMORAN BLVD STE A
ORLANDO FL
32822-2472
US

IV. Provider business mailing address

4445 S SEMORAN BLVD STE A
ORLANDO FL
32822-2472
US

V. Phone/Fax

Practice location:
  • Phone: 407-203-8957
  • Fax: 407-985-1904
Mailing address:
  • Phone: 407-203-8957
  • Fax: 407-985-1904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberME151342
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME151342
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: