Provider Demographics
NPI:1962837419
Name:LACANDOLA, MARIE DESIREE VILLARUZ (APRN)
Entity type:Individual
Prefix:
First Name:MARIE DESIREE
Middle Name:VILLARUZ
Last Name:LACANDOLA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:DESIREE
Other - Middle Name:
Other - Last Name:LACANDOLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:2400 N ORANGE BLOSSOM TRL
Mailing Address - Street 2:SUITE 302
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-2306
Mailing Address - Country:US
Mailing Address - Phone:407-932-6193
Mailing Address - Fax:
Practice Address - Street 1:201 HILDA ST STE 12
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2359
Practice Address - Country:US
Practice Address - Phone:407-933-6626
Practice Address - Fax:407-933-6628
Is Sole Proprietor?:No
Enumeration Date:2013-09-03
Last Update Date:2020-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9271357363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010300300Medicaid