Provider Demographics
NPI:1023279916
Name:BAGENHOLM, ALLYSON CHRISTINA (MD)
Entity type:Individual
Prefix:
First Name:ALLYSON
Middle Name:CHRISTINA
Last Name:BAGENHOLM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 CLINT MOORE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33496-2660
Mailing Address - Country:US
Mailing Address - Phone:561-757-5530
Mailing Address - Fax:561-430-3590
Practice Address - Street 1:1905 CLINT MOORE RD STE 202
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33496-2660
Practice Address - Country:US
Practice Address - Phone:561-757-5530
Practice Address - Fax:561-430-3590
Is Sole Proprietor?:No
Enumeration Date:2008-06-23
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT051025207Q00000X
FLME115466207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1023279916OtherNPI