Provider Demographics
NPI:1477017341
Name:LOFTIS, SUSAN L
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:LOFTIS
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 1:6423 BOLD VENTURE TRL
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32309-1905
Mailing Address - Country:US
Mailing Address - Phone:850-591-2372
Mailing Address - Fax:
Practice Address - Street 1:6423 BOLD VENTURE TRL
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32309-1905
Practice Address - Country:US
Practice Address - Phone:850-591-2372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-25
Last Update Date:2019-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1000733103747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant