1659362424 NPI number — MRS. DRINA GERALDINE PORTMAN DNP, APRN-BC

Table of content: JESSICA R PRIEST LLPC (NPI 1801509922)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659362424 NPI number — MRS. DRINA GERALDINE PORTMAN DNP, APRN-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PORTMAN
Provider First Name:
DRINA
Provider Middle Name:
GERALDINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
DNP, APRN-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659362424
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7406 FULLERTON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32256-3552
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
305-336-2711
Provider Business Mailing Address Fax Number:
954-920-9855

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7406 FULLERTON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32256-3552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-336-2711
Provider Business Practice Location Address Fax Number:
954-920-9855
Provider Enumeration Date:
11/02/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  APRN2621802 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 302867400 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: APRN2621802 . This is a "FLORIDA BOARD OF NURSING" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".
  • Identifier: 116558500 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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