Provider Demographics
NPI:1215063680
Name:MAMCZUR, NINETTE (AP)
Entity type:Individual
Prefix:
First Name:NINETTE
Middle Name:
Last Name:MAMCZUR
Suffix:
Gender:F
Credentials:AP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 BARTON BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2710
Mailing Address - Country:US
Mailing Address - Phone:321-633-1400
Mailing Address - Fax:321-799-8306
Practice Address - Street 1:400 BARTON BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2710
Practice Address - Country:US
Practice Address - Phone:321-633-1400
Practice Address - Fax:321-799-8306
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 1588171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDOC 1057564OtherACUPUNCTURIST