Provider Demographics
NPI:1720566482
Name:ILNYCKYJ, MANDY MICHELLE (APRN)
Entity type:Individual
Prefix:
First Name:MANDY
Middle Name:MICHELLE
Last Name:ILNYCKYJ
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4457 BAYOU BLVD
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-2601
Mailing Address - Country:US
Mailing Address - Phone:850-226-6801
Mailing Address - Fax:877-413-5104
Practice Address - Street 1:4457 BAYOU BLVD
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32503
Practice Address - Country:US
Practice Address - Phone:850-226-6801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-03
Last Update Date:2020-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-158696363LF0000X
FLAPRN9328758363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily