Provider Demographics
NPI:1437893633
Name:MINICK, DANA DALE
Entity Type:Individual
Prefix:
First Name:DANA
Middle Name:DALE
Last Name:MINICK
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 1:12461 MORNING GLORY LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913-8313
Mailing Address - Country:US
Mailing Address - Phone:239-216-2501
Mailing Address - Fax:
Practice Address - Street 1:12461 MORNING GLORY LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33913-8313
Practice Address - Country:US
Practice Address - Phone:239-216-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-24
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1291311164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse