Basic Information
| Provider Information | |||||||||
| NPI: | 1245248871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MIODEK | ||||||||
| FirstName: | SHAWN | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | ARNP, CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3466 N HARBOR CITY BLVD | ||||||||
| Address2: | |||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329355713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3214341982 | ||||||||
| FaxNumber: | 3219517408 | ||||||||
| Practice Location | |||||||||
| Address1: | 7125 MURRELL RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MELBOURNE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329407999 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3217575141 | ||||||||
| FaxNumber: | 3217519362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 03/23/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LX0001X | ARNP9291971 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Obstetrics & Gynecology | 367A00000X | ARNP9291971 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363L00000X | ARNP9291971 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 002172900 | 05 | FL | MEDICAID |