1770275406 NPI number — GRAYSON SHEA VERITY FNP

Table of content: GRAYSON SHEA VERITY FNP (NPI 1770275406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770275406 NPI number — GRAYSON SHEA VERITY FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VERITY
Provider First Name:
GRAYSON
Provider Middle Name:
SHEA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770275406
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4221 BOCA WOODS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORLANDO
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32826-2611
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
407-539-4300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2609 S ORANGE AVE STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORLANDO
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32806-4533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
407-641-2444
Provider Business Practice Location Address Fax Number:
407-200-2392
Provider Enumeration Date:
05/22/2023

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  11025511 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 118497900 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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