Provider Demographics
NPI:1255944609
Name:MIKE, RAYNA ELICE
Entity type:Individual
Prefix:
First Name:RAYNA
Middle Name:ELICE
Last Name:MIKE
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 1:9400 TURKEY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819-8001
Mailing Address - Country:US
Mailing Address - Phone:321-842-8505
Mailing Address - Fax:321-843-5550
Practice Address - Street 1:9400 TURKEY LAKE RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819-8001
Practice Address - Country:US
Practice Address - Phone:321-842-8505
Practice Address - Fax:321-843-5550
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-26
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11008868363L00000X
FLAPRN11008868363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner