Provider Demographics
NPI:1528228996
Name:FORMICA, MISTEE L (CNM)
Entity Type:Individual
Prefix:
First Name:MISTEE
Middle Name:L
Last Name:FORMICA
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E PRINCETON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-5555
Mailing Address - Country:US
Mailing Address - Phone:407-303-1444
Mailing Address - Fax:407-303-1446
Practice Address - Street 1:235 E PRINCETON ST STE 200
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-5555
Practice Address - Country:US
Practice Address - Phone:407-303-1444
Practice Address - Fax:407-303-1446
Is Sole Proprietor?:No
Enumeration Date:2008-06-10
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC431367A00000X
FLAPRN11026120367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7002155Medicaid