Provider Demographics
NPI:1295299451
Name:PTAK, MALGORZATA
Entity type:Individual
Prefix:
First Name:MALGORZATA
Middle Name:
Last Name:PTAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 FARMBROOK RD
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-6243
Mailing Address - Country:US
Mailing Address - Phone:386-767-1613
Mailing Address - Fax:
Practice Address - Street 1:158 FARMBROOK RD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-6243
Practice Address - Country:US
Practice Address - Phone:386-767-1613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-22
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL5650310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility