Provider Demographics
NPI:1083007926
Name:UDRIS, ANDA
Entity type:Individual
Prefix:
First Name:ANDA
Middle Name:
Last Name:UDRIS
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 1:1200 FLORAL SPRINGS BLVD
Mailing Address - Street 2:#12104
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-6800
Mailing Address - Country:US
Mailing Address - Phone:513-739-6346
Mailing Address - Fax:
Practice Address - Street 1:600 S CLYDE MORRIS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-3966
Practice Address - Country:US
Practice Address - Phone:386-226-6417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-17
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL37122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer