=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265975940
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANA A CRUZ I
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/29/2016
-----------------------------------------------------
Last Update Date | 11/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 815 EYRIE DR STE 1A
-----------------------------------------------------
City | OVIEDO
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32765-8602
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-927-6215
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1956 N HIGHLANDS BLVD
-----------------------------------------------------
City | AVON PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33825-8179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 863-453-3151
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 172V00000X
-----------------------------------------------------
Taxonomy Name | Community Health Worker
-----------------------------------------------------
License Number | 29133537
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------