Provider Demographics
NPI:1538926993
Name:MANDY, DEJA (APRN)
Entity type:Individual
Prefix:
First Name:DEJA
Middle Name:
Last Name:MANDY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:DEJA
Other - Middle Name:
Other - Last Name:MANDY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:1839 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8900
Mailing Address - Country:US
Mailing Address - Phone:727-322-1054
Mailing Address - Fax:727-821-7213
Practice Address - Street 1:1839 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8900
Practice Address - Country:US
Practice Address - Phone:727-322-1054
Practice Address - Fax:727-821-7213
Is Sole Proprietor?:No
Enumeration Date:2024-03-04
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11023581363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL121835800Medicaid
FL4EA8COtherBCBS