Provider Demographics
NPI:1124156468
Name:AWANTANG, NIMAE N (MD)
Entity type:Individual
Prefix:DR
First Name:NIMAE
Middle Name:N
Last Name:AWANTANG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NIMAE
Other - Middle Name:N
Other - Last Name:ANGWAFO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1702 OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444
Mailing Address - Country:US
Mailing Address - Phone:850-571-5844
Mailing Address - Fax:850-571-5845
Practice Address - Street 1:625 W. BALDWIN RD STE C.
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405
Practice Address - Country:US
Practice Address - Phone:850-769-6612
Practice Address - Fax:850-769-3553
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL23996208D00000X
FLME113443207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008348000Medicaid
FL008348000Medicaid