Provider Demographics
NPI:1730453325
Name:PHANISNARAINE, ANN REBECCA
Entity type:Individual
Prefix:MRS
First Name:ANN
Middle Name:REBECCA
Last Name:PHANISNARAINE
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 1:2873 MAGNOLIA BLOSSOM CIR
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-7498
Mailing Address - Country:US
Mailing Address - Phone:321-297-4634
Mailing Address - Fax:
Practice Address - Street 1:2873 MAGNOLIA BLOSSOM CIR
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-7498
Practice Address - Country:US
Practice Address - Phone:321-297-4634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-29
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004318500Medicaid