Healthcare Provider Details

I. General information

NPI: 1982919106
Provider Name (Legal Business Name): MARY ELLEN HUCKESTEIN ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 N 35TH AVE SUITE 135
HOLLYWOOD FL
33021-5424
US

IV. Provider business mailing address

1150 N 35TH AVE SUITE 135
HOLLYWOOD FL
33021-5424
US

V. Phone/Fax

Practice location:
  • Phone: 954-265-6989
  • Fax: 954-965-3599
Mailing address:
  • Phone: 954-265-6989
  • Fax: 954-965-3599

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1402192
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: