Provider Demographics
NPI:1063854040
Name:NAYAK, BRENDA ITHIER (AP)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:ITHIER
Last Name:NAYAK
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6706 AMBASSADOR DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32818-4023
Mailing Address - Country:US
Mailing Address - Phone:407-473-5494
Mailing Address - Fax:321-245-7199
Practice Address - Street 1:1081 WP BALL BLVD
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-7201
Practice Address - Country:US
Practice Address - Phone:407-328-7595
Practice Address - Fax:407-328-7372
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2013-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1940171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLAP1940OtherACUPUNCTURE LICENSE