MEDICARE: DAVID ETHAN MAMBU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	APRN11044264	FL
2	363L00000X	Nurse Practitioner	11044264	FL

General Provider Information

NPI Number	:	1295601516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID ETHAN MAMBU

Provider Business Mailing Address
First Line	:	2413 FALLEN TREE DR W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-4141
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2413 FALLEN TREE DR W
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32246-4141
Country	:	US
Telephone Number	:	571-330-4633
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/14/2025
Last Update Date	:	12/18/2025

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Directions to “ DAVID ETHAN MAMBU ” Practice Location

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