Provider Demographics
NPI:1154586048
Name:MOSELLE, MARIANNE
Entity type:Individual
Prefix:MRS
First Name:MARIANNE
Middle Name:
Last Name:MOSELLE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6652 GLEN MEADOW LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-5881
Mailing Address - Country:US
Mailing Address - Phone:863-607-9611
Mailing Address - Fax:863-859-5350
Practice Address - Street 1:6652 GLEN MEADOW LOOP
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33810-5881
Practice Address - Country:US
Practice Address - Phone:863-255-7300
Practice Address - Fax:863-859-5350
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL593286346171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL67-7735000Medicaid