Provider Demographics
NPI:1265942791
Name:MONGIELLO, MICHAEL JAMES (MSN, MA, NP-C, RN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JAMES
Last Name:MONGIELLO
Suffix:
Gender:M
Credentials:MSN, MA, NP-C, RN
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:239-343-9567
Mailing Address - Fax:239-343-9571
Practice Address - Street 1:8925 COLONIAL CENTER DR STE 2001
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905
Practice Address - Country:US
Practice Address - Phone:239-343-9567
Practice Address - Fax:239-343-6571
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9382978364SX0200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SX0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022992200Medicaid