Provider Demographics
NPI:1962435271
Name:MICHELLE R DEMENKOW, PA
Entity type:Organization
Organization Name:MICHELLE R DEMENKOW, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:DEMENKOW
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:954-856-8703
Mailing Address - Street 1:14201 W SUNRISE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:SUNRISE
Mailing Address - State:FL
Mailing Address - Zip Code:33323-3207
Mailing Address - Country:US
Mailing Address - Phone:954-851-9690
Mailing Address - Fax:
Practice Address - Street 1:14201 W SUNRISE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323
Practice Address - Country:US
Practice Address - Phone:954-851-9690
Practice Address - Fax:954-366-5056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY6763103TC0700X
FLARNP9211884363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8819Medicare PIN