Provider Demographics
NPI:1619438348
Name:DOUGLAS, ANNYELLA MARI
Entity Type:Individual
Prefix:
First Name:ANNYELLA
Middle Name:MARI
Last Name:DOUGLAS
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 1:3 SW 129TH AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33027-1778
Mailing Address - Country:US
Mailing Address - Phone:866-400-3376
Mailing Address - Fax:954-217-3222
Practice Address - Street 1:3 SW 129TH AVE STE 100
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33027-1778
Practice Address - Country:US
Practice Address - Phone:866-400-3376
Practice Address - Fax:954-217-3222
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME163979207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology