Healthcare Provider Details

I. General information

NPI: 1205944097
Provider Name (Legal Business Name): ATTIYA ALI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 09/24/2021
Certification Date: 09/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2105 PALM BAY RD. NE SUITE 3
PALM BAY FL
32905-2937
US

IV. Provider business mailing address

2105 PALM BAY RD NE STE 3
PALM BAY FL
32905-2937
US

V. Phone/Fax

Practice location:
  • Phone: 321-984-8808
  • Fax: 321-676-7011
Mailing address:
  • Phone: 321-984-8808
  • Fax: 321-676-7011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberME0062108
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: