Provider Demographics
NPI:1033409032
Name:BACCHIOCCHI, LORETTA (ARNP)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:
Last Name:BACCHIOCCHI
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 N MILLS AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-5734
Mailing Address - Country:US
Mailing Address - Phone:407-841-1100
Mailing Address - Fax:407-649-8677
Practice Address - Street 1:1115 E. RIDGEWOOD STREET
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803
Practice Address - Country:US
Practice Address - Phone:407-841-1100
Practice Address - Fax:407-841-0774
Is Sole Proprietor?:No
Enumeration Date:2011-04-11
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9174215363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL017737900Medicaid
FLFB811ZMedicare PIN