Basic Information
| Provider Information | |||||||||
| NPI: | 1578532669 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MOREAU | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PREDMORE | ||||||||
| OtherFirstName: | ANNA | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1290 GOLFVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | BARTOW | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338306738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8635197900 | ||||||||
| FaxNumber: | 8635197696 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 W CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE WALES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338534015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636784144 | ||||||||
| FaxNumber: | 8636784000 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | X | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | ARNP357582 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.