1639479900 NPI number — JENNIFER MARIE BLOODWORTH FNP-BC

Table of content: JENNIFER MARIE BLOODWORTH FNP-BC (NPI 1639479900)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639479900 NPI number — JENNIFER MARIE BLOODWORTH FNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLOODWORTH
Provider First Name:
JENNIFER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FAZIO
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1639479900
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1137
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MELBOURNE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32902-1137
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-952-9696
Provider Business Mailing Address Fax Number:
321-952-7937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5270 BABCOCK ST NE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
PALM BAY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32905-8630
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-722-5959
Provider Business Practice Location Address Fax Number:
321-722-5960
Provider Enumeration Date:
11/02/2010

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: 363LF0000X , with the licence number:  ARNP9310812 , 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: 003241600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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