Provider Demographics
NPI:1033432265
Name:WADE, MANDI H (ARNP, CNM)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:H
Last Name:WADE
Suffix:
Gender:F
Credentials:ARNP, CNM
Other - Prefix:
Other - First Name:MANDI
Other - Middle Name:
Other - Last Name:MAZURKIEWICZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-7100
Mailing Address - Fax:239-343-7190
Practice Address - Street 1:4040 PALM BEACH BLVD STE F
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33916-3470
Practice Address - Country:US
Practice Address - Phone:239-343-7100
Practice Address - Fax:239-343-7190
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9277738367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001942600Medicaid