MEDICARE: GRACE LINDA MIMMACK OHNSTAD

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	163WC0200X	Critical Care Medicine Registered Nurse	RN9635023	FL

General Provider Information

NPI Number	:	1740170067
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRACE LINDA MIMMACK OHNSTAD

Provider Business Mailing Address
First Line	:	2175 JUDGE FRAN JAMIESON WAY APT 307
Second Line	:
City	:	MELBOURNE
State	:	FL
Zip	:	32940-6177
Country	:	US
Telephone Number	:	720-224-2116
Fax Number	:

Provider Business Practice Location Address
First Line	:	1405 S ORANGE AVE STE 500
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32806-2153
Country	:	US
Telephone Number	:	305-899-3230
Fax Number	:

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

Provider Enumeration Date	:	07/08/2025
Last Update Date	:	07/08/2025

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