Provider Demographics
NPI:1184212425
Name:SCANLAN, ANNAELLE ROSE
Entity Type:Individual
Prefix:
First Name:ANNAELLE
Middle Name:ROSE
Last Name:SCANLAN
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 1:5153 ROMA ST
Mailing Address - Street 2:
Mailing Address - City:AVE MARIA
Mailing Address - State:FL
Mailing Address - Zip Code:34142-5052
Mailing Address - Country:US
Mailing Address - Phone:239-651-9524
Mailing Address - Fax:
Practice Address - Street 1:15049 BRUCE B DOWNS BLVD
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-1388
Practice Address - Country:US
Practice Address - Phone:813-563-7668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113434363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant