Provider Demographics
NPI:1083143713
Name:LOUDER, JISELLE
Entity Type:Individual
Prefix:MRS
First Name:JISELLE
Middle Name:
Last Name:LOUDER
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 1:1440 ORCHID LN
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-2775
Mailing Address - Country:US
Mailing Address - Phone:407-319-2108
Mailing Address - Fax:
Practice Address - Street 1:12014 E COLONIAL DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4750
Practice Address - Country:US
Practice Address - Phone:407-319-2108
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-06
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty