Provider Demographics
NPI:1821344292
Name:COBBS, RAQUEL
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:COBBS
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 1:9314 LAKE FISCHER BLVD
Mailing Address - Street 2:
Mailing Address - City:GOTHA
Mailing Address - State:FL
Mailing Address - Zip Code:34734-5203
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9314 LAKE FISCHER BLVD
Practice Address - Street 2:
Practice Address - City:GOTHA
Practice Address - State:FL
Practice Address - Zip Code:34734-5203
Practice Address - Country:US
Practice Address - Phone:407-294-3872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL251B00000X172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692707698Medicaid
FL692707696Medicaid