Healthcare Provider Details

I. General information

NPI: 1518781392
Provider Name (Legal Business Name): MARK MIELNICZEK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2024
Last Update Date: 02/17/2025
Certification Date: 02/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 TAMIAMI TRL E
NAPLES FL
34112-7476
US

IV. Provider business mailing address

4520 BOTANICAL PLACE CIR APT 104
NAPLES FL
34112-2401
US

V. Phone/Fax

Practice location:
  • Phone: 508-926-9339
  • Fax:
Mailing address:
  • Phone: 508-926-9339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11037618
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: