Healthcare Provider Details

I. General information

NPI: 1720566482
Provider Name (Legal Business Name): MANDY MICHELLE ILNYCKYJ APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2018
Last Update Date: 04/24/2020
Certification Date: 04/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4457 BAYOU BLVD
PENSACOLA FL
32503
US

IV. Provider business mailing address

4457 BAYOU BLVD
PENSACOLA FL
32503-2601
US

V. Phone/Fax

Practice location:
  • Phone: 850-226-6801
  • Fax:
Mailing address:
  • Phone: 850-226-6801
  • Fax: 877-413-5104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-158696
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN9328758
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: