Provider Demographics
NPI:1063185247
Name:AXSON, ISHA LEIGH
Entity type:Individual
Prefix:
First Name:ISHA
Middle Name:LEIGH
Last Name:AXSON
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 1:217 W POLK ST APT 12
Mailing Address - Street 2:
Mailing Address - City:AUBURNDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33823-3535
Mailing Address - Country:US
Mailing Address - Phone:863-521-7287
Mailing Address - Fax:
Practice Address - Street 1:217 W POLK ST APT 12
Practice Address - Street 2:
Practice Address - City:AUBURNDALE
Practice Address - State:FL
Practice Address - Zip Code:33823-3535
Practice Address - Country:US
Practice Address - Phone:863-521-7287
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities