Provider Demographics
NPI:1417218942
Name:CONCENGCO, MARY JANE (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:JANE
Last Name:CONCENGCO
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 1:1115 E. RIDGEWOOD STREET
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803
Mailing Address - Country:US
Mailing Address - Phone:407-841-1100
Mailing Address - Fax:407-650-0262
Practice Address - Street 1:1115 E. RIDGEWOOD STREET
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803
Practice Address - Country:US
Practice Address - Phone:407-841-1100
Practice Address - Fax:407-650-0262
Is Sole Proprietor?:No
Enumeration Date:2012-05-31
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA585935163W00000X
MI4704229396163W00000X
FLARNP9180792363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse