1528207552 NPI number — MONIQUE M. BERCES-MARDENLY FNP, MSN, MPH

Table of content: MS. NANCY SNIDER MS (NPI 1336552124)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528207552 NPI number — MONIQUE M. BERCES-MARDENLY FNP, MSN, MPH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERCES-MARDENLY
Provider First Name:
MONIQUE
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP, MSN, MPH
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528207552
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 DR CARTER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BUNNELL
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32110-6212
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-437-7350
Provider Business Mailing Address Fax Number:
386-437-7353

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
301 DR CARTER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BUNNELL
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32110-6212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-437-7350
Provider Business Practice Location Address Fax Number:
386-437-7353
Provider Enumeration Date:
02/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  18296 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LF0000X , with the licence number: APRN11002491 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0276496 . This is a "L AND I" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 1528207552 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01169704 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 113245500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com