Basic Information
| Provider Information | |||||||||
| NPI: | 1134634249 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MERCADO | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | |||||||||
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| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | MERCADO | ||||||||
| OtherFirstName: | ANDREA | ||||||||
| OtherMiddleName: | LEE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1630 MASON AVE | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321174500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862389064 | ||||||||
| FaxNumber: | 3869449746 | ||||||||
| Practice Location | |||||||||
| Address1: | 1630 MASON AVE STE C | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321174503 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3862810939 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2017 | ||||||||
| LastUpdateDate: | 08/14/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN9426002 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | ARNP9426002 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | APRN9426002 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.