Healthcare Provider Details

I. General information

NPI: 1588222814
Provider Name (Legal Business Name): ITUMELENG M NCUBE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2019
Last Update Date: 09/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4451 BAYOU BLVD
PENSACOLA FL
32503-2601
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-7619
  • Fax: 850-416-7753
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN11001611
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: