Provider Demographics
NPI:1588286637
Name:SCOTT, CHRISANA LATAE
Entity type:Individual
Prefix:
First Name:CHRISANA
Middle Name:LATAE
Last Name:SCOTT
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 1:2995 EAGLE NEST VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-3220
Mailing Address - Country:US
Mailing Address - Phone:863-514-7501
Mailing Address - Fax:
Practice Address - Street 1:2995 EAGLE NEST VIEW DR
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-3220
Practice Address - Country:US
Practice Address - Phone:863-514-7501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-12
Last Update Date:2020-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL101533400376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101533400Medicaid