NPI |
1205116324 |
The State code in the location of the provider
being identified. |
Entity Type Code |
1 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
Provider Last Name Legal Name |
CHURCHILL |
The last name of the provider. If the provider is an individual, this is the legal name. |
Provider First Name |
ALISHA |
The first name of the provider, if the provider
is an individual. |
Provider Middle Name |
M |
The middle name of the provider, if the provider
is an individual. |
Provider Credential Text |
PT |
The date the provider was assigned a unique identifier (assigned an NPI). |
Provider Other Last Name |
COVER |
The date that a record was last updated or changed. |
Provider Other First Name |
ALISHA |
The code designating the provider’s gender if the provider is a person. |
Provider Other Credential Text |
PTA |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
Provider Other Last Name Type Code |
2 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider First Line Business Practice Location Address |
5445 MURRELL RD STE 105 |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Provider Business Practice Location Address City Name |
ROCKLEDGE |
|
Provider Business Practice Location Address State Name |
FL |
|
Provider Business Practice Location Address Postal Code |
329556679 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider Business Practice Location Address Country Code If outside U S |
US |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Provider Business Practice Location Address Telephone Number |
3218025807 |
|
Provider Enumeration Date |
8/19/2011 |
|
Last Update Date |
10/21/2020 |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Provider Gender Code |
F |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Healthcare Provider Taxonomy Code 1 |
225100000X |
|
Provider License Number 1 |
32150 |
|
Provider License Number State Code 1 |
FL |
The license number issued to the provider being identified. The NPS can accommodate
multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with ‘‘provider taxonomy code’’. |
Healthcare Provider Primary Taxonomy Switch 1 |
Y |
The code representing the State that issued the license to the provider being identified. This field can accommodate multiple States. It is associated with ‘‘provider license number. |
Is Sole Proprietor |
N |
|
NPI Certification Date |
10/21/2020 |
|