Provider Demographics
NPI:1487191508
Name:FORD, NEPHATARI
Entity Type:Individual
Prefix:
First Name:NEPHATARI
Middle Name:
Last Name:FORD
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 1:24901 SW 130TH AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:FL
Mailing Address - Zip Code:33032-4100
Mailing Address - Country:US
Mailing Address - Phone:305-890-4886
Mailing Address - Fax:
Practice Address - Street 1:24901 SW 130TH AVE APT 101
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:FL
Practice Address - Zip Code:33032-4100
Practice Address - Country:US
Practice Address - Phone:305-890-4886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-26
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL19000249211332B00000X, 332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies