Provider Demographics
NPI:1104353168
Name:ABUKHODEIR, SUMMER
Entity type:Individual
Prefix:
First Name:SUMMER
Middle Name:
Last Name:ABUKHODEIR
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:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-2812
Practice Address - Street 1:858 REDWOOD WAY
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33898-9130
Practice Address - Country:US
Practice Address - Phone:863-232-7604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9384750363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLJ2DQTOtherBLUE CROSS BLUE SHIELD
FL105431300Medicaid
FLL6972OtherMEDICARE