1144662362 NPI number — MRS. NICKETRIS SIMMONS MANDELA PHARMD

Table of content: MRS. NICKETRIS SIMMONS MANDELA PHARMD (NPI 1144662362)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144662362 NPI number — MRS. NICKETRIS SIMMONS MANDELA PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANDELA
Provider First Name:
NICKETRIS
Provider Middle Name:
SIMMONS
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
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:
1144662362
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13480 NW 4TH ST APT 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEMBROKE PINES
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33028-2240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
954-235-2477
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5701 NW 183RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIALEAH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33015-6022
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-625-0952
Provider Business Practice Location Address Fax Number:
305-623-7742
Provider Enumeration Date:
07/30/2013

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: 183500000X , with the licence number:  PS50810 , 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)





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