Provider Demographics
NPI:1326767757
Name:SUMMERALL, HOPE JAMIA
Entity type:Individual
Prefix:
First Name:HOPE
Middle Name:JAMIA
Last Name:SUMMERALL
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 1:401 S STATE ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:BUNNELL
Mailing Address - State:FL
Mailing Address - Zip Code:32110-6191
Mailing Address - Country:US
Mailing Address - Phone:407-885-6517
Mailing Address - Fax:
Practice Address - Street 1:401 S STATE ST UNIT C
Practice Address - Street 2:
Practice Address - City:BUNNELL
Practice Address - State:FL
Practice Address - Zip Code:32110-6191
Practice Address - Country:US
Practice Address - Phone:407-885-6517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLC401K5KWZ4335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL871124644Medicaid