Provider Demographics
NPI:1699488999
Name:VON ZIMMERMAN, MARINA
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:VON ZIMMERMAN
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 1:1890 LPGA BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32117-7138
Mailing Address - Country:US
Mailing Address - Phone:386-252-4701
Mailing Address - Fax:386-253-9410
Practice Address - Street 1:1890 LPGA BLVD STE 160
Practice Address - Street 2:
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32117-7138
Practice Address - Country:US
Practice Address - Phone:386-252-4701
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-02
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116871363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant