Provider Demographics
NPI:1740286061
Name:MANISCALCO, DERONDA L (APRN)
Entity type:Individual
Prefix:
First Name:DERONDA
Middle Name:L
Last Name:MANISCALCO
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 2699
Mailing Address - Street 2:ATTN: SHMG/HPE
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-478-2333
Mailing Address - Fax:850-478-1809
Practice Address - Street 1:400 MILESTONE BLVD
Practice Address - Street 2:
Practice Address - City:CANTONMENT
Practice Address - State:FL
Practice Address - Zip Code:32533-6579
Practice Address - Country:US
Practice Address - Phone:850-478-2333
Practice Address - Fax:850-478-1809
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2016-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9187672363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305011400Medicaid
FLY004YOtherBCBS
FL305011400Medicaid