Provider Demographics
NPI:1104551035
Name:SUMPTER, MISCHKA
Entity type:Individual
Prefix:
First Name:MISCHKA
Middle Name:
Last Name:SUMPTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1631 E 19TH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-3350
Mailing Address - Country:US
Mailing Address - Phone:904-444-7801
Mailing Address - Fax:
Practice Address - Street 1:1631 E 19TH ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32206-3350
Practice Address - Country:US
Practice Address - Phone:904-444-7801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-24
Last Update Date:2022-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLL21000383658253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care