Provider Demographics
NPI:1619653607
Name:ABERNATHY, ALEXIS BRIANNA
Entity Type:Individual
Prefix:
First Name:ALEXIS
Middle Name:BRIANNA
Last Name:ABERNATHY
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 1:1877 FORTUNE RD
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-4428
Mailing Address - Country:US
Mailing Address - Phone:407-943-8618
Mailing Address - Fax:407-932-5150
Practice Address - Street 1:1507 BILL BECK BLVD
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-9516
Practice Address - Country:US
Practice Address - Phone:407-943-8618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2024-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009811152W00000X
FLOPC6433152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist