Basic Information
| Provider Information | |||||||||
| NPI: | 1912667064 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CENTENO | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 379 BLAZE BLVD | ||||||||
| Address2: | |||||||||
| City: | FREEPORT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 324392386 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805532692 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2190 HIGHWAY 85 N | ||||||||
| Address2: | |||||||||
| City: | NICEVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325781045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506784131 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2021 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.