1023668092 NPI number — MICHELLE R MOTTERN APRN

Table of content: MICHELLE R MOTTERN APRN (NPI 1023668092)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023668092 NPI number — MICHELLE R MOTTERN APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOTTERN
Provider First Name:
MICHELLE
Provider Middle Name:
R
Provider Name Prefix Text:
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:
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:
1023668092
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 GREGORY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURNDALE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33823-2320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
863-255-6449
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7225 N NEBRASKA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33604-4916
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-236-1182
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/12/2019

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: 2084A0401X , with the licence number:  2021031024 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207Q00000X , with the licence number: 11002262 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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