Provider Demographics
NPI:1629180807
Name:WOMBLE, ALISA S (PCA)
Entity Type:Individual
Prefix:MRS
First Name:ALISA
Middle Name:S
Last Name:WOMBLE
Suffix:
Gender:F
Credentials:PCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3342 SW HOSANAH LN
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34974-2218
Mailing Address - Country:US
Mailing Address - Phone:772-597-5021
Mailing Address - Fax:772-597-5021
Practice Address - Street 1:3342 SW HOSANAH LN
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34974-2218
Practice Address - Country:US
Practice Address - Phone:772-597-5021
Practice Address - Fax:772-597-5021
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health