Provider Demographics
NPI:1922050129
Name:DEHANEY-DUFFUS, CASSANDRA
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:DEHANEY-DUFFUS
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 1:1400 COLONIAL BLVD
Mailing Address - Street 2:SUITE #1
Mailing Address - City:FT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13813 METRO PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4343
Practice Address - Country:US
Practice Address - Phone:239-931-3440
Practice Address - Fax:239-931-3454
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3168072363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ25001Medicare UPIN
FLU3420ZMedicare ID - Type Unspecified