Provider Demographics
NPI:1316306269
Name:MAZYCK, DONNA MICHELE (NP)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MICHELE
Last Name:MAZYCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 ELM ST STE 202B
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2284
Mailing Address - Country:US
Mailing Address - Phone:844-341-2339
Mailing Address - Fax:203-907-1234
Practice Address - Street 1:324 ELM ST STE 202B
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:CT
Practice Address - Zip Code:06468-2284
Practice Address - Country:US
Practice Address - Phone:844-341-2339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP015914363LA2200X
NJ26NJ00620700363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1316306269Medicare UPIN