1750718771 NPI number — MARIE MANOUCHKA NICOLAS ARNP

Table of content: MARIE MANOUCHKA NICOLAS ARNP (NPI 1750718771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750718771 NPI number — MARIE MANOUCHKA NICOLAS ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICOLAS
Provider First Name:
MARIE
Provider Middle Name:
MANOUCHKA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NICOLAS-VALCIN
Provider Other First Name:
MARIE
Provider Other Middle Name:
MANOUCHKA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ARNP
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1750718771
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6101 BLUE LAGOON DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMI
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33126-2051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-756-9977
Provider Business Mailing Address Fax Number:
305-756-5757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6269 NW 7TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MIAMI
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33150-4394
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-756-9977
Provider Business Practice Location Address Fax Number:
844-473-2961
Provider Enumeration Date:
10/04/2013

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: 363LF0000X , with the licence number:  ARNP 9169790 , 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: 110387600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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