Provider Demographics
NPI:1972904381
Name:SUMMERS, JANICE
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:
Last Name:SUMMERS
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 1:1225 SW GRANDVIEW ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0740
Mailing Address - Country:US
Mailing Address - Phone:386-466-0005
Mailing Address - Fax:386-438-5368
Practice Address - Street 1:1225 SW GRANDVIEW ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0740
Practice Address - Country:US
Practice Address - Phone:386-466-0005
Practice Address - Fax:386-438-5368
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL9402310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL693311400Medicaid