Provider Demographics
NPI:1396011748
Name:PEDROGO, LEDDATALIZ (LPN)
Entity type:Individual
Prefix:
First Name:LEDDATALIZ
Middle Name:
Last Name:PEDROGO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 ELLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:DUNDEE
Mailing Address - State:FL
Mailing Address - Zip Code:33838-4633
Mailing Address - Country:US
Mailing Address - Phone:407-724-4853
Mailing Address - Fax:
Practice Address - Street 1:4762 BREEZER DR
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33859-5447
Practice Address - Country:US
Practice Address - Phone:407-724-4853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5198865385H00000X, 385HR2055X, 385HR2060X, 385HR2065X, 164W00000X, 251E00000X, 251J00000X, 261QD1600X, 372600000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No385H00000XRespite Care FacilityRespite Care
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
No251E00000XAgenciesHome Health
No251J00000XAgenciesNursing Care
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
No372600000XNursing Service Related ProvidersAdult Companion
No376K00000XNursing Service Related ProvidersNurse's Aide