Healthcare Provider Details

I. General information

NPI: 1548341530
Provider Name (Legal Business Name): MIMI MARIE ZUGEL FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 03/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 HERITAGE VILLAGE PLZ SUITE 101
GAINESVILLE VA
20155-3069
US

IV. Provider business mailing address

7200 HERITAGE VILLAGE PLZ SUITE 101
GAINESVILLE VA
20155-3069
US

V. Phone/Fax

Practice location:
  • Phone: 571-261-4165
  • Fax:
Mailing address:
  • Phone: 571-261-4165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024132769
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: