Provider Demographics
NPI:1598250169
Name:ALONSO, PAMELA FAITH
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:FAITH
Last Name:ALONSO
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 1:715 RIVERBEND BLVD
Mailing Address - Street 2:
Mailing Address - City:LONGWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:32779-2347
Mailing Address - Country:US
Mailing Address - Phone:321-947-2002
Mailing Address - Fax:
Practice Address - Street 1:715 RIVERBEND BLVD
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-2347
Practice Address - Country:US
Practice Address - Phone:321-947-2002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA4093235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPENDINGMedicaid