Basic Information
| Provider Information | |||||||||
| NPI: | 1114140860 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REICHERT | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | JILL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1700 SE HILLMOOR DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349527539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723359600 | ||||||||
| FaxNumber: | 7723987951 | ||||||||
| Practice Location | |||||||||
| Address1: | 1700 SE HILLMOOR DR | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PORT ST LUCIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 349527539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7723359600 | ||||||||
| FaxNumber: | 7723987951 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2007 | ||||||||
| LastUpdateDate: | 08/20/2009 | ||||||||
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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 | 363L00000X | ARNP3144302 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 3089614000 | 05 | FL | MEDICAID |