Provider Demographics
NPI:1720552367
Name:FELICIANO, BECKY
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:
Last Name:FELICIANO
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 1:1320 LONG ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33801-2926
Mailing Address - Country:US
Mailing Address - Phone:863-513-5715
Mailing Address - Fax:
Practice Address - Street 1:1320 LONG ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-2926
Practice Address - Country:US
Practice Address - Phone:863-513-5715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-16
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104009500Medicaid