Provider Demographics
NPI:1568562544
Name:ZACK, DONNA (APRN)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:
Last Name:ZACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-0550
Mailing Address - Fax:239-343-4013
Practice Address - Street 1:13340 METRO PKWY STE 200
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33966
Practice Address - Country:US
Practice Address - Phone:239-343-0550
Practice Address - Fax:239-343-4013
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002328363LA2100X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL102841200Medicaid
NY0456G0Z691Medicare PIN