Provider Demographics
NPI:1063606614
Name:DEMENKOW, MICHELLE RENE (PHD)
Entity type:Individual
Prefix:MISS
First Name:MICHELLE
Middle Name:RENE
Last Name:DEMENKOW
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14201 W SUNRISE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-3207
Mailing Address - Country:US
Mailing Address - Phone:954-851-9690
Mailing Address - Fax:
Practice Address - Street 1:14201 W SUNRISE BLVD
Practice Address - Street 2:SUITE 208
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-3207
Practice Address - Country:US
Practice Address - Phone:954-851-9690
Practice Address - Fax:954-851-9688
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6763103TC0700X
FLARNP9211884363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL17568900Medicaid