Basic Information
Provider Information | |||||||||
NPI: | 1265942791 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MONGIELLO | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | JAMES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSN, MA, NP-C, RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2147 | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 339022147 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2393439567 | ||||||||
FaxNumber: | 2393439571 | ||||||||
Practice Location | |||||||||
Address1: | 8925 COLONIAL CENTER DR STE 2001 | ||||||||
Address2: |   | ||||||||
City: | FORT MYERS | ||||||||
State: | FL | ||||||||
PostalCode: | 33905 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2393439567 | ||||||||
FaxNumber: | 2393436571 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/11/2017 | ||||||||
LastUpdateDate: | 03/31/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/31/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SX0200X | APRN9382978 | FL | N |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Oncology | 363LG0600X | APRN9382978 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
ID | Type | State | Issuer | Description | 022992200 | 05 | FL |   | MEDICAID |