Healthcare Provider Details

I. General information

NPI: 1891091732
Provider Name (Legal Business Name): JACQUELINE MEMMINGER MOT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JACKIE MEMMINGER MOT

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 NW 76TH DR
GAINESVILLE FL
32607-6668
US

IV. Provider business mailing address

5638 SWAMP FOX RD
JACKSONVILLE FL
32210-7312
US

V. Phone/Fax

Practice location:
  • Phone: 352-505-6363
  • Fax: 352-505-6383
Mailing address:
  • Phone: 904-294-3990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMOT14504
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: