Provider Demographics
NPI:1154500056
Name:DUCOIN, MATTIE GALLAGHER (CNM)
Entity Type:Individual
Prefix:
First Name:MATTIE
Middle Name:GALLAGHER
Last Name:DUCOIN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:MATTIE
Other - Middle Name:
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:
Practice Address - Street 1:2 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606
Practice Address - Country:US
Practice Address - Phone:813-974-2201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMW206176B00000X
LAAP08269367A00000X
VA0024170143367A00000X
FLAPRN9369604367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014267600Medicaid
FLY0P9LOtherBLUE CROSS BLUE SHIELD
MS07956874Medicaid
FLKX359OtherMEDICARE
LA2418718Medicaid
LA2418718Medicaid