Provider Demographics
NPI:1043805633
Name:CANNEDY-BYRD, RAINA L
Entity type:Individual
Prefix:
First Name:RAINA
Middle Name:L
Last Name:CANNEDY-BYRD
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 1:5015 QUEEN PALM DR
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-5912
Mailing Address - Country:US
Mailing Address - Phone:813-506-2057
Mailing Address - Fax:
Practice Address - Street 1:5015 QUEEN PALM DR
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-5912
Practice Address - Country:US
Practice Address - Phone:813-506-2057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL813518338Medicaid