Provider Demographics
NPI:1316306269
Name:MAZYCK, DONNA MICHELE (NP)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:MICHELE
Last Name:MAZYCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1221 N CHURCH ST STE 103-D
Mailing Address - Street 2:
Mailing Address - City:MOORESTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08057-1245
Mailing Address - Country:US
Mailing Address - Phone:609-337-2211
Mailing Address - Fax:609-543-2433
Practice Address - Street 1:1221 N CHURCH ST STE 103-D
Practice Address - Street 2:
Practice Address - City:MOORESTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08057-1245
Practice Address - Country:US
Practice Address - Phone:609-847-0538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-21
Last Update Date:2025-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00620700202D00000X, 207RB0002X, 207RG0300X, 261QP2300X, 363LA2200X
NJ26NJ00720700261QI0500X
PASP015914363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No202D00000XAllopathic & Osteopathic PhysiciansIntegrative Medicine
No207RB0002XAllopathic & Osteopathic PhysiciansInternal MedicineObesity Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1316306269Medicare UPIN