Provider Demographics
NPI:1477177004
Name:SPACE COAST ADVANCED PRACTICE CONSULTANTS LLC
Entity Type:Organization
Organization Name:SPACE COAST ADVANCED PRACTICE CONSULTANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAKEECIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CANNION
Authorized Official - Suffix:
Authorized Official - Credentials:APRN-C
Authorized Official - Phone:321-795-7386
Mailing Address - Street 1:1838 WADENA ST NW
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32907-8511
Mailing Address - Country:US
Mailing Address - Phone:321-795-7386
Mailing Address - Fax:
Practice Address - Street 1:115 HICKORY ST STE 204
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-3505
Practice Address - Country:US
Practice Address - Phone:321-795-7386
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016947100Medicaid