Provider Demographics
NPI:1922585496
Name:HABIB, LAILA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:LAILA
Middle Name:NICOLE
Last Name:HABIB
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 SANDY GARDEN LN
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-9385
Mailing Address - Country:US
Mailing Address - Phone:352-988-4324
Mailing Address - Fax:
Practice Address - Street 1:175 W PINE AVE
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32750-4168
Practice Address - Country:US
Practice Address - Phone:321-207-0172
Practice Address - Fax:321-201-0175
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLPA9111509363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL120544200Medicaid