Provider Demographics
NPI:1679661326
Name:GARANCOSKY, MARLENE IRENE (NP)
Entity type:Individual
Prefix:MS
First Name:MARLENE
Middle Name:IRENE
Last Name:GARANCOSKY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:MAGGIE
Other - Middle Name:
Other - Last Name:GARANCOSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:10442 SCOTT MILL RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-6228
Mailing Address - Country:US
Mailing Address - Phone:904-465-3004
Mailing Address - Fax:
Practice Address - Street 1:10442 SCOTT MILL RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32257-6228
Practice Address - Country:US
Practice Address - Phone:904-465-3004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1613692363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL500019531OtherRR MEDICARE
FLP00011942OtherRR MEDICARE
FL303544101Medicaid
FLP00011943OtherRR MEDICARE
FLP00867788Medicare PIN
FLY8761VMedicare ID - Type Unspecified
FLP25720Medicare UPIN
FLY8761XMedicare ID - Type Unspecified
FL303544101Medicaid
FLY8761YMedicare ID - Type Unspecified