Provider Demographics
NPI:1912323056
Name:IGNACIO, EDITHA
Entity Type:Individual
Prefix:
First Name:EDITHA
Middle Name:
Last Name:IGNACIO
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 1:1636 E SHANGRI LA DR
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32119-1520
Mailing Address - Country:US
Mailing Address - Phone:386-767-8048
Mailing Address - Fax:
Practice Address - Street 1:1636 E SHANGRI LA DR
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32119-1520
Practice Address - Country:US
Practice Address - Phone:386-767-8048
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11691310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001574900Medicaid