Provider Demographics
NPI:1235672411
Name:BACCHUS, FARA
Entity Type:Individual
Prefix:MRS
First Name:FARA
Middle Name:
Last Name:BACCHUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FARA
Other - Middle Name:
Other - Last Name:BACCHUS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ARNP
Mailing Address - Street 1:464 GOLDENMOSS LOOP
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-4781
Mailing Address - Country:US
Mailing Address - Phone:407-963-7693
Mailing Address - Fax:
Practice Address - Street 1:832 W CENTRAL BLVD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32805-1809
Practice Address - Country:US
Practice Address - Phone:407-858-1400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-21
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 3036332364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL020035000Medicaid