Provider Demographics
NPI:1861999088
Name:MASCOE, COURTNEY NICOLE
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:MASCOE
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 1:700 6TH ST S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33701-4815
Mailing Address - Country:US
Mailing Address - Phone:727-893-6116
Mailing Address - Fax:727-553-7340
Practice Address - Street 1:700 6TH ST S
Practice Address - Street 2:FAMILY CARE CENTER
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701
Practice Address - Country:US
Practice Address - Phone:727-893-6116
Practice Address - Fax:727-553-7340
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME145880207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL122985600Medicaid
FLNOIV3OtherBCBS