Healthcare Provider Details

I. General information

NPI: 1053130955
Provider Name (Legal Business Name): WENDY SUE PLOURD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 CLYDE MORRIS BLVD
ORMOND BEACH FL
32174-5993
US

IV. Provider business mailing address

1100 OAK FOREST CIR
PORT ORANGE FL
32129-4178
US

V. Phone/Fax

Practice location:
  • Phone: 386-269-8458
  • Fax:
Mailing address:
  • Phone: 678-760-6030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number17804
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: