Healthcare Provider Details

I. General information

NPI: 1871173328
Provider Name (Legal Business Name): MISCHELLE ANN MBONU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 N DILLARD ST
WINTER GARDEN FL
34787-2816
US

IV. Provider business mailing address

411 N DILLARD ST
WINTER GARDEN FL
34787-2816
US

V. Phone/Fax

Practice location:
  • Phone: 407-296-1600
  • Fax:
Mailing address:
  • Phone: 407-296-1600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number9414439
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: