Provider Demographics
NPI:1225457484
Name:MCENNAN, DAISSY CAROLINA (MD)
Entity Type:Individual
Prefix:DR
First Name:DAISSY
Middle Name:CAROLINA
Last Name:MCENNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:DAISSY
Other - Middle Name:CAROLINA
Other - Last Name:DOMINGUEZ MARQUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:17 DAVIS BLVD
Mailing Address - Street 2:SUITE 308
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33606-3475
Mailing Address - Country:US
Mailing Address - Phone:813-250-2506
Mailing Address - Fax:
Practice Address - Street 1:17 DAVIS BLVD
Practice Address - Street 2:SUITE 308
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606
Practice Address - Country:US
Practice Address - Phone:813-396-2515
Practice Address - Fax:813-905-9896
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2018-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program