Provider Demographics
NPI:1891120747
Name:LAO, NENILLA F
Entity type:Individual
Prefix:MS
First Name:NENILLA
Middle Name:F
Last Name:LAO
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 1:1012 GULF RD
Mailing Address - Street 2:
Mailing Address - City:TARPON SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34689-2532
Mailing Address - Country:US
Mailing Address - Phone:727-938-0973
Mailing Address - Fax:727-938-0973
Practice Address - Street 1:1012 GULF RD
Practice Address - Street 2:
Practice Address - City:TARPON SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34689-2532
Practice Address - Country:US
Practice Address - Phone:727-938-0973
Practice Address - Fax:727-938-0973
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-11
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL7977310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL140789900Medicaid
FLAL7977OtherAHCA LICENSE