Provider Demographics
NPI:1417609074
Name:ATEHORTUA, LADY
Entity Type:Individual
Prefix:
First Name:LADY
Middle Name:
Last Name:ATEHORTUA
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 1:229 DUNCAN TRL
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-4512
Mailing Address - Country:US
Mailing Address - Phone:321-438-2857
Mailing Address - Fax:
Practice Address - Street 1:401 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5750
Practice Address - Country:US
Practice Address - Phone:407-502-0073
Practice Address - Fax:407-502-3009
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11017671363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily