Basic Information
Provider Information | |||||||||
NPI: | 1639403173 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MERCER | ||||||||
FirstName: | IDA | ||||||||
MiddleName: | LOU | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | A.R.N.P. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4024 CENTRAL AVE | ||||||||
Address2: |   | ||||||||
City: | ST PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337111239 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7273277656 | ||||||||
FaxNumber: | 7273238978 | ||||||||
Practice Location | |||||||||
Address1: | 4024 CENTRAL AVE. | ||||||||
Address2: |   | ||||||||
City: | ST. PETERSBURG | ||||||||
State: | FL | ||||||||
PostalCode: | 337330970 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7273277656 | ||||||||
FaxNumber: | 7273238978 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/01/2009 | ||||||||
LastUpdateDate: | 10/01/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SP0809X | ARNP429242 | FL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult |
No ID Information.