Provider Demographics
NPI:1043883077
Name:CLAXTON, CECILIA V
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:V
Last Name:CLAXTON
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:PO BOX 100888
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32910-0888
Mailing Address - Country:US
Mailing Address - Phone:321-987-1524
Mailing Address - Fax:321-674-1566
Practice Address - Street 1:2638 WESTSIDE AVE SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-7678
Practice Address - Country:US
Practice Address - Phone:321-953-2590
Practice Address - Fax:321-674-1566
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL120396310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility