=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841820537
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAENA OAKLEY OTR/L
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2020
-----------------------------------------------------
Last Update Date | 01/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1705 JESS PARRISH CT
-----------------------------------------------------
City | TITUSVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32796-2158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-269-5720
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 341 TUSCANY WAY APT 310
-----------------------------------------------------
City | MELBOURNE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32940-8189
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 321-704-4284
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 20601
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------