Provider Demographics
NPI:1164151197
Name:DEDMON, COREY
Entity Type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:DEDMON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4923 PATAGONIA PL
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34638-3733
Mailing Address - Country:US
Mailing Address - Phone:813-862-8341
Mailing Address - Fax:
Practice Address - Street 1:4923 PATAGONIA PL
Practice Address - Street 2:
Practice Address - City:LAND O LAKES
Practice Address - State:FL
Practice Address - Zip Code:34638-3733
Practice Address - Country:US
Practice Address - Phone:813-862-8341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11020067363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner