Provider Demographics
NPI:1043972110
Name:PHANORD, JOSIANE
Entity Type:Individual
Prefix:
First Name:JOSIANE
Middle Name:
Last Name:PHANORD
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 1:3941 NW 45TH WAY
Mailing Address - Street 2:
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-4729
Mailing Address - Country:US
Mailing Address - Phone:175-442-2147
Mailing Address - Fax:
Practice Address - Street 1:7100 W COMMERCIAL BLVD
Practice Address - Street 2:
Practice Address - City:LAUDERHILL
Practice Address - State:FL
Practice Address - Zip Code:33319-2155
Practice Address - Country:US
Practice Address - Phone:754-206-2953
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA15230224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP563-420-85-548-0Medicaid