Provider Demographics
NPI:1295165835
Name:FIDELIA, MYCHAU (NP)
Entity type:Individual
Prefix:
First Name:MYCHAU
Middle Name:
Last Name:FIDELIA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 NEBRASKA AVE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34950-4837
Mailing Address - Country:US
Mailing Address - Phone:772-465-4499
Mailing Address - Fax:
Practice Address - Street 1:1900 NEBRASKA AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34950-4837
Practice Address - Country:US
Practice Address - Phone:772-465-4499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-18
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9266631363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner