Provider Demographics
NPI:1083695266
Name:LANDSBERGER, MARY (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:LANDSBERGER
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4740 EXPLORATION AVE
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33812-3319
Mailing Address - Country:US
Mailing Address - Phone:863-666-9020
Mailing Address - Fax:863-606-0887
Practice Address - Street 1:4740 EXPLORATION AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33812-3319
Practice Address - Country:US
Practice Address - Phone:863-666-9020
Practice Address - Fax:863-606-0887
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1469442363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP1469442OtherARNP LICENSE NUMBER
FLE5483AOtherWELLMED MEDICAL MANAGEMENT OF FLORIDA INC