Basic Information
Provider Information | |||||||||
NPI: | 1063447993 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CERECEDA | ||||||||
FirstName: | ADELAIDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2234 COLONIAL BLVD | ||||||||
Address2: | ATTN: PAYER CONTRACTING & RELATIONS DEPT. | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339071412 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2399317342 | ||||||||
FaxNumber: | 2399317385 | ||||||||
Practice Location | |||||||||
Address1: | 7335 GLADIOLUS DR | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339085101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2399851925 | ||||||||
FaxNumber: | 2393216044 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 12/29/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | ARNP2951012 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 1249034 | 01 | FL | WELLCARE | OTHER | Y114U | 01 | FL | BCBS OF FL | OTHER | 9279891 | 01 | FL | AETNA | OTHER | P01318679 | 01 | FL | RR MEDICARE | OTHER | P954066 | 01 | FL | OPTIMUM | OTHER | 308158300 | 05 | FL |   | MEDICAID | 398577 | 01 | FL | AVMED | OTHER | P114547 | 01 | FL | FREEDOM | OTHER |