Provider Demographics
NPI:1619430246
Name:MAZON, LENORA (MMA)
Entity Type:Individual
Prefix:
First Name:LENORA
Middle Name:
Last Name:MAZON
Suffix:
Gender:F
Credentials:MMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:HAVANA
Mailing Address - State:FL
Mailing Address - Zip Code:32333-1915
Mailing Address - Country:US
Mailing Address - Phone:850-616-5005
Mailing Address - Fax:
Practice Address - Street 1:307A S MAIN ST
Practice Address - Street 2:
Practice Address - City:HAVANA
Practice Address - State:FL
Practice Address - Zip Code:32333-2007
Practice Address - Country:US
Practice Address - Phone:850-616-5005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-10
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172A00000X, 251C00000X, 253Z00000X, 347C00000X, 372600000X, 376J00000X, 385H00000X, 385HR2065X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No172A00000XOther Service ProvidersDriver
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No253Z00000XAgenciesIn Home Supportive Care
No347C00000XTransportation ServicesPrivate Vehicle
No372600000XNursing Service Related ProvidersAdult Companion
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0401Medicaid