Provider Demographics
NPI:1871173328
Name:MBONU, MISCHELLE ANN
Entity type:Individual
Prefix:
First Name:MISCHELLE
Middle Name:ANN
Last Name:MBONU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N DILLARD ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-2816
Mailing Address - Country:US
Mailing Address - Phone:407-296-1600
Mailing Address - Fax:
Practice Address - Street 1:411 N DILLARD ST
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-2816
Practice Address - Country:US
Practice Address - Phone:407-296-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-09
Last Update Date:2021-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9414439163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator