=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699556506
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | D'ERICA DIONE OATES CRANIAL PROTHESIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2023
-----------------------------------------------------
Last Update Date | 10/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1022 W SR 436 STE 1000
-----------------------------------------------------
City | ALTAMONTE SPG
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32714-2919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 689-227-3434
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1972 CRANBERRY ISLES WAY
-----------------------------------------------------
City | APOPKA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32712-2144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 407-508-0377
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | K0NUM2LGWU
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------