Healthcare Provider Details

I. General information

NPI: 1740170067
Provider Name (Legal Business Name): GRACE LINDA MIMMACK OHNSTAD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2025
Last Update Date: 07/08/2025
Certification Date: 07/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 S ORANGE AVE STE 500
ORLANDO FL
32806-2153
US

IV. Provider business mailing address

2175 JUDGE FRAN JAMIESON WAY APT 307
MELBOURNE FL
32940-6177
US

V. Phone/Fax

Practice location:
  • Phone: 305-899-3230
  • Fax:
Mailing address:
  • Phone: 720-224-2116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN9635023
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: