Provider Demographics
NPI:1043715915
Name:ALFRED, PHYLLIS
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:ALFRED
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 STRATTON AVE
Mailing Address - Street 2:
Mailing Address - City:GROVELAND
Mailing Address - State:FL
Mailing Address - Zip Code:34736-8203
Mailing Address - Country:US
Mailing Address - Phone:352-209-1322
Mailing Address - Fax:
Practice Address - Street 1:1121 STRATTON AVE
Practice Address - Street 2:
Practice Address - City:GROVELAND
Practice Address - State:FL
Practice Address - Zip Code:34736-8203
Practice Address - Country:US
Practice Address - Phone:352-321-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-24
Last Update Date:2018-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker