Healthcare Provider Details

I. General information

NPI: 1194199364
Provider Name (Legal Business Name): SHREE ANITHA PRASANNA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2015
Last Update Date: 03/28/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1490 CHENEY HWY
TITUSVILLE FL
32780-6250
US

IV. Provider business mailing address

1490 CHENEY HWY
TITUSVILLE FL
32780-6250
US

V. Phone/Fax

Practice location:
  • Phone: 321-267-3304
  • Fax: 321-267-9191
Mailing address:
  • Phone: 321-267-3304
  • Fax: 321-267-9191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: SHREE ANITHA PRASANNA
Title or Position: ADMINISTRATOR OFFICER
Credential:
Phone: 321-268-0108