=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396011748
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEDDATALIZ PEDROGO LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/30/2012
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4762 BREEZER DR
-----------------------------------------------------
City | LAKE WALES
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33859-5447
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-724-4853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1615 ELLINGTON DR
-----------------------------------------------------
City | DUNDEE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33838-4633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-724-4853
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number | PN5198865
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 385HR2055X
-----------------------------------------------------
Taxonomy Name | Child Mental Illness Respite Care
-----------------------------------------------------
License Number | PN5198865
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 385HR2060X
-----------------------------------------------------
Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
-----------------------------------------------------
License Number | PN5198865
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 385HR2065X
-----------------------------------------------------
Taxonomy Name | Child Physical Disabilities Respite Care
-----------------------------------------------------
License Number | PN5198865
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 164W00000X
-----------------------------------------------------
Taxonomy Name | Licensed Practical Nurse
-----------------------------------------------------
License Number | PN5198865
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | PN5198865
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 251J00000X
-----------------------------------------------------
Taxonomy Name | Nursing Care Agency
-----------------------------------------------------
License Number | PN5198865
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 261QD1600X
-----------------------------------------------------
Taxonomy Name | Developmental Disabilities Clinic/Center
-----------------------------------------------------
License Number | PN5198865
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 372600000X
-----------------------------------------------------
Taxonomy Name | Adult Companion
-----------------------------------------------------
License Number | PN5198865
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 376K00000X
-----------------------------------------------------
Taxonomy Name | Nurse's Aide
-----------------------------------------------------
License Number | PN5198865
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------