1598919714 NPI number — MS. MARCIA KAY PETERZELL APRN

Table of content: MS. MARCIA KAY PETERZELL APRN (NPI 1598919714)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598919714 NPI number — MS. MARCIA KAY PETERZELL APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERZELL
Provider First Name:
MARCIA
Provider Middle Name:
KAY
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ERHARDT
Provider Other First Name:
MARCIA
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598919714
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1275 W GRANADA BLVD STE 3A
Provider Second Line Business Mailing Address:
COASTAL PEDIATRICS LLC
Provider Business Mailing Address City Name:
ORMOND BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32174
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-672-1490
Provider Business Mailing Address Fax Number:
386-672-1682

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1275 W GRANADA BLVD. STE 3A
Provider Second Line Business Practice Location Address:
COASTAL PEDIATRICS LLC
Provider Business Practice Location Address City Name:
ORMOND BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32174
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-672-1490
Provider Business Practice Location Address Fax Number:
386-672-1682
Provider Enumeration Date:
11/14/2008

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: 363LP0200X , with the licence number:  APRN3136772 , 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: ARNP3136772 . This is a "STOFFL/DOH" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 105185500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".