Provider Demographics
NPI:1558035717
Name:BOMORT, DEAISA ZHANE
Entity Type:Individual
Prefix:
First Name:DEAISA
Middle Name:ZHANE
Last Name:BOMORT
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 1:1836 N CRYSTAL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-6576
Mailing Address - Country:US
Mailing Address - Phone:863-738-9493
Mailing Address - Fax:
Practice Address - Street 1:1836 N CRYSTAL LAKE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-6576
Practice Address - Country:US
Practice Address - Phone:863-738-9493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-02
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLB563179949530172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver