Healthcare Provider Details

I. General information

NPI: 1386567451
Provider Name (Legal Business Name): AQUANETTA LAKISSIA FELIX CCMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2026
Last Update Date: 08/04/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 WOODS AVE APT A
ORLANDO FL
32805-3158
US

IV. Provider business mailing address

810 WOODS AVE APT A
ORLANDO FL
32805-3158
US

V. Phone/Fax

Practice location:
  • Phone: 407-591-6654
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberG4F5D9S2
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: