Provider Demographics
NPI:1124772520
Name:ANNIKEY, PAULETTE ANNMARIE
Entity type:Individual
Prefix:
First Name:PAULETTE
Middle Name:ANNMARIE
Last Name:ANNIKEY
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 1:415 EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34759-4432
Mailing Address - Country:US
Mailing Address - Phone:863-547-4886
Mailing Address - Fax:863-547-4993
Practice Address - Street 1:415 EAGLE DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34759-4432
Practice Address - Country:US
Practice Address - Phone:863-547-4886
Practice Address - Fax:863-547-4993
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-05
Last Update Date:2022-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL692345396320800000X, 320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL692345396Medicaid
FL320600000XMedicaid