Healthcare Provider Details

I. General information

NPI: 1619210861
Provider Name (Legal Business Name): MLACSON RNFA SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/05/2013
Last Update Date: 03/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 ROLLER LN
PALM COAST FL
32164-8939
US

IV. Provider business mailing address

PO BOX 350031
PALM COAST FL
32135-0031
US

V. Phone/Fax

Practice location:
  • Phone: 386-503-9731
  • Fax:
Mailing address:
  • Phone: 386-503-9731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP 9270072
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberARNP 9270072
License Number StateFL

VIII. Authorized Official

Name: MS. MARILENE GOPEZ LACSON
Title or Position: OWNER/ADMINSITRATOR
Credential: ARNP
Phone: 386-503-9731