Provider Demographics
NPI:1114268364
Name:PAGAN, DAPHNE YVETTE (MBA)
Entity Type:Individual
Prefix:
First Name:DAPHNE
Middle Name:YVETTE
Last Name:PAGAN
Suffix:
Gender:F
Credentials:MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 VISTA GRAND WAY APT. 104
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32824
Mailing Address - Country:US
Mailing Address - Phone:321-337-2329
Mailing Address - Fax:407-382-0659
Practice Address - Street 1:3201 BUDINGER AVE.
Practice Address - Street 2:
Practice Address - City:ST. CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769
Practice Address - Country:US
Practice Address - Phone:407-891-3054
Practice Address - Fax:407-382-0659
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-13
Last Update Date:2018-01-05
Deactivation Date:2017-11-30
Deactivation Code:
Reactivation Date:2018-01-05
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator