Provider Demographics
NPI:1609121367
Name:FITZGERALD, NANCY MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:MARIE
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 MEIGS DR
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-2200
Mailing Address - Country:US
Mailing Address - Phone:850-543-6200
Mailing Address - Fax:
Practice Address - Street 1:7650 38TH AVE N
Practice Address - Street 2:A
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1233
Practice Address - Country:US
Practice Address - Phone:727-343-8831
Practice Address - Fax:727-345-5396
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-18
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 198421223G0001X
AZD 85491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice