1386809424 NPI number — MISS MARIELLE GRACE SHOFFSTALL LMT

Table of content: MISS MARIELLE GRACE SHOFFSTALL LMT (NPI 1386809424)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386809424 NPI number — MISS MARIELLE GRACE SHOFFSTALL LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOFFSTALL
Provider First Name:
MARIELLE
Provider Middle Name:
GRACE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
LMT
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:
1386809424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10218 MISTY MEADOW RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEESBURG
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34788-3300
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-617-5121
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10401 US HIGHWAY 441
Provider Second Line Business Practice Location Address:
SUITE 326
Provider Business Practice Location Address City Name:
LEESBURG
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34788-8787
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-365-6155
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/28/2008

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: 225700000X , with the licence number:  MA48313 , 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)





Copyright © 2007-2025 www.npivalidator.com