Provider Demographics
NPI:1164495396
Name:RAUCH, MARSHA KIDDER (ARNP, PHD)
Entity Type:Individual
Prefix:DR
First Name:MARSHA
Middle Name:KIDDER
Last Name:RAUCH
Suffix:
Gender:F
Credentials:ARNP, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 WEST LAKE BRANTLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4766
Mailing Address - Country:US
Mailing Address - Phone:407-869-1450
Mailing Address - Fax:
Practice Address - Street 1:2000 PREVATT ST
Practice Address - Street 2:SUITE B3
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-6149
Practice Address - Country:US
Practice Address - Phone:407-869-1450
Practice Address - Fax:407-574-4625
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-08
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP518912363LA2200X, 363LG0600X, 364SP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE5442Medicare PIN
FLP30499Medicare UPIN