Provider Demographics
NPI:1205905486
Name:CHURCH, ANN ALLISA (MD)
Entity type:Individual
Prefix:DR
First Name:ANN
Middle Name:ALLISA
Last Name:CHURCH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:ALLISA
Other - Last Name:BAUERNFIEND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14275 MIDWAY RD STE 400
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-3661
Mailing Address - Country:US
Mailing Address - Phone:866-697-8378
Mailing Address - Fax:610-271-4245
Practice Address - Street 1:132 DUNDEE PL
Practice Address - Street 2:
Practice Address - City:ST JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-8223
Practice Address - Country:US
Practice Address - Phone:800-330-6770
Practice Address - Fax:954-633-3217
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME97605207N00000X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001485600Medicaid
CH568ZMedicare PIN